What is separation anxiety disorder?
Separation anxiety disorder (SAD) is a condition in which a person experiences extreme fear or distress when separated from an emotional attachment, usually a parent but it can also be from any loved person or a place they feel safe.
Experiencing separation anxiety as a young child is a normal part of development. In fact, if a child does not experience some separation anxiety, this could indicate that they do not have a secure attachment to their caregiver.
When infants reach about 8 months old, they learn object permanence, meaning that they know people and objects can exist even when they are out of sight. Whilst they understand that they still exist, the child is not always convinced that their loved one will return.
This can cause some separation anxiety until the age of about 3 or 4, until the child matures emotionally, and the anxiety resolves on its own.
When the separation anxiety persists after this time, occurs in older children, adolescents, or adults, or when it causes debilitating anxiety, it may be that the person has SAD.
SAD is a more intense and intrusive condition which can interfere with daily functioning, well-being, academic or work life, or physical health.
People with this condition will find it extremely challenging to be separated from their loved one and it may present as extreme worry, excessive crying, or physical symptoms such as headaches or stomach aches. Some of the symptoms of SAD may overlap with those of panic disorder and other anxiety disorders.
SAD is the most common anxiety disorder diagnosed in children, accounting for around 50% of diagnoses (Ehrenreich et al., 2008). Approximately 3-4% of children have SAD (Walker et al., 2009) and up to 6.6% of adults will experience SAD (Silove et al., 2010).
Sometimes a person with SAD as an adult may have had the condition as a child, whilst others may only experience it in adulthood.
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The symptoms of SAD are usually excessive for the individual’s developmental age. It can cause significant distress in daily functioning and anxiety-related behaviours.
Below are some of the cognitive symptoms of SAD:
Recurrent and excessive distress about anticipating being away from loved ones
Recurrent and excessive distress about being away from loved ones
Constant and excessive worry about losing a loved one to an illness or disaster
Constant worry that something bad will happen, resulting in separation from a loved one
Not wanting to be home alone without a loved one
Needing to know where a loved one is at all times
Feeling anxious about being alone in a room
Excessive worry about something bad happening to themselves
Having exaggerated and irrational fears of things like the dark, monster, or burglars
Nightmares, specifically about separation
Those with SAD exhibit varying degrees of avoidant behaviours that correlate with the severity of their symptoms. Below are some of the behavioural symptoms of SAD:
Extreme and severe crying
Refusal to do anything that requires separation
Emotional temper tantrums
Failure to interact with other children in a healthy way
Refusing to sleep alone
Staying close to a parent or loved one, even within the home
Being shy and socially withdrawn
In older children with SAD, they may experience school-specific behaviours since school can be a major stressor for their anxiety. They may feign illnesses or experience headaches when it is time to go to school.
The illness tends to go away once the child is allowed to stay at home, but it may reappear again before school the next day.
The child may have ‘meltdowns’ or refuse to say goodbye in the hopes of not being separated from the loved one.
Although children with SAD may feign illnesses, they can also experience physical symptoms such as headaches, vomiting, bedwetting, stomach aches, nausea, or problems with sleeping.
Due to SAD, there are many complications that can manifest as a result:
Poorer school performance
Can result in other anxiety disorders if left untreated
Low social performance and high social anxiety
Difficulty initiating and maintaining friendships
Family activities being limited by negative behaviours
Parents of child with SAD having little to no time for themselves or each other
Siblings becoming jealous of all the extra attention given to the child with SAD
Adult SAD can be very debilitating. Someone with adult SAD may have problems with their job performance such as lacking concentration, coming in to work late, or leaving early.
They may find it difficult maintaining employment in general. Adults with SAD may also have difficulties with social and romantic relationships.
They may be seen as too clingy if they are constantly wanting to be with or know where their friends/romantic partners are.
They may also be seen as annoying and dramatic if they are always expressing worries about the safety of their friends/romantic partners or always expecting something bad to happen.
What can cause separation anxiety disorder?
SAD may manifest due to environmental factors, especially changes in the environment such as:
A change in caregiver
Change in routine
Following a traumatic event
Change in parent availability
Change in family structure e.g., through divorce or illness
Starting a new school
After any life change, even if it’s a positive change
Specifically for adults with SAD, this may develop when dealing with the breakdown of a relationship.
Parents may also develop SAD when their child becomes more independent, no longer relies solely on their parents, or moves away from the family home.
Secure attachment is important for a child’s development. It could be that SAD could be linked to a child’s attachment style to their primary caregiver.
Early experiences of having an insecure attachment style may affect a child’s ability to bond with others and feel safe away from their loved ones.
Likewise, parenting that is overly critical, controlling, or overprotective may interfere with a child’s normal development of autonomy, as well as contributing to anxiety disorders.
It’s been suggested that the effects of parenting styles can be seen in both childhood and after a person enters adulthood (Dabkowska et al., 2011).
Most children with anxiety disorder usually come from middle-to upper-income families. However, those with SAD tend to come from low-income households (Jones, 2021).
This could suggest that the financial stress within a family could be a contributing factor for young children to develop SAD and insecure attachments.
SAD may be related to another underlying mental health condition, such as delusions from psychotic disorders or fear of change relating to autism spectrum disorders.
Those with SAD also seem to be more at risk of having other coexisting conditions such as social phobias, panic disorders, or agoraphobia. It is therefore likely that these other conditions may fuel the likelihood of SAD developing.
Certain temperaments or personalities of individuals are considered to be more prone to anxiety disorders than others. Specifically, those with timid or shy personalities may be a risk factor for the development of SAD.
Studies have found that low extraversion combined with high neuroticism may play a role in the onset of anxiety disorders (Gershuny & Sher, 1998; Griffith et al., 2010).
Another risk factor of someone developing SAD is if a blood relative has a history of mental health conditions.
Data suggests that SAD is 20-40% heritable from a biological parent (Fox & Kalin, 2014) therefore a child is likely to develop anxiety from their parents.
A diagnosis of SAD involves determining whether the child is going through a normal stage of development or if the issue is actually a disorder. A doctor may perform medical tests to rule out any physical conditions. After this, the child’s Paediatrician may refer the parent to a child psychologist or psychiatrist with expertise in anxiety disorders.
To help diagnose SAD, the professional will likely give the child a psychological evaluation, including a structured interview that involves discussing thoughts and feelings.
To diagnose adults, providers primarily rely on self-report methods. Since children cannot reliably be assessed with adult self-reports, parents and professionals must use other methods.
This may involve watching how the parent interacts with the child, which can show whether the parenting style affects how the child deals with anxiety. The parents can also play a role in the assessment by relaying observations they have made of their child.
The Children’s Separation Anxiety Scale (CSAS) lists child-accessible questions such as ‘Do you worry about getting lost?’ and ‘Do you think about going home to be with your mom or dad when you’re at school?’. These child-accessible questions assess whether a child has SAD symptoms.
The DSM-5 defines SAD as a developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidence by at least 3 of the following:
Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
Persistent reluctance or refusal to sleep away from home or in other settings.
TherapyRepeated nightmares involving the theme of separation.
Repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
The fear, anxiety, or avoidance must be persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
According to the DSM-5, the disturbance should cause clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
Finally, for a diagnosis of SAD to be made, the symptoms should not be better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in ASD; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in GAD; or concerns about having an illness in illness anxiety disorder.
The most widely effective type of therapy is cognitive behavioural therapy (CBT). CBT aims to help a person to identify their thoughts and behaviours that are making their SAD worse.
With a therapist, the person will learn to change their negative thought patterns that are unhealthy, and replace them with ones that are adaptive and productive.
Sessions usually last about 12-16 weeks and can teach people with SAD coping techniques for their anxiety, using techniques such as deep breathing and relaxation.
The person with SAD can learn how to face and manage their fears about separation and uncertainty. In addition, parents can get involved in the sessions to learn how to effectively provide emotional support and encourage age-appropriate independence.
Parent-child interaction therapy may also be useful for those with SAD. This therapy usually has three main treatment phases:
Child-directed interaction – focuses on improving the quality of the parent-child relationship with the aim to strengthen the child’s feelings of safety.
Bravery-directed interaction – educates the parents about why their child feels anxious. The therapist will develop a bravery ladder which shows situations that cause anxious feelings and establishes rewards for positive reactions.
Parent-directed interaction – this teaches parents how to communicate clearly with the child so they can help manage negative behaviours from their child.
Other types of therapy include psychotherapy, sometimes called talk therapy, which involves working with a therapist to talk through and reduce SAD symptoms.
Support groups may also be useful for those who have SAD. People who join these groups can gain assistance with learning techniques for reducing SAD symptoms in a group environment.
This type of treatment for SAD is used on children and is based on positive reinforcement . The child and the parent will agree on a set of goals.
When these goals are met, the parent can give the child a reward. This reward can be anything that the child values such as stickers or extra TV time.
The goal of this treatment operates on the principle that positive behaviours that get rewarded will get repeated.
Exposure therapy works on the idea that confronting your fears gives the person a chance to see that their fears are irrational. This usually involves gradually exposing someone to their feared situation, such as being left without a loved one.
This can start small, such as talking about the idea of being left alone, before working up towards being left alone for increasingly longer amounts of time until the person feels comfortable being away from their loved one.
Many times, CBT is often paired with exposure-based treatments, whilst providing people with SAD with ways of coping other than escape and avoidance.
There are no specific medications for the treatment of SAD. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are sometimes used in older children if other forms of treatment are ineffective, but these must be closely monitored for side effects.
Doctors may temporarily prescribe anti-anxiety medications to help a person with their most acute symptoms. However, these are not always long-term solutions to the underlying disorder and some types of anti-anxiety medications can be addictive.
Medications are rarely prescribed as the first-line of treatment to children but for adults, SSRIs may be prescribed on their own, but are more effective as part of a combination therapy.
Do you need mental health support?
If you or a loved one are struggling with symptoms of an anxiety disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline for information on support and treatment facilities in your area.
Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email firstname.lastname@example.org .
Availiale 24 hours day, 365 days a year (this number is FREE to call):
Rethink Mental Illness: rethink.org
0300 5000 927
Administration SA and MHS. Table 15, dsm-iv to dsm-5 separation anxiety disorder comparison. Updated June 2016.
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