Separation Anxiety Disorder

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Separation anxiety disorder facts

  • Infants show stranger anxiety by crying when someone unfamiliar approaches.
  • Separation anxiety as a normal life stage first develops at about 7 months of age, once object permanence has been established. It is at its strongest at 10-18 months of age and usually subsides by 3 years of age.
  • Separation anxiety disorder is a normal stage of development that usually begins in childhood and is characterized by worrying out of proportion to the situation of temporarily leaving home or otherwise separating from loved ones.
  • Approximately 4%-5% of children and adolescents suffer from separation anxiety disorder.
  • Examples of separation anxiety disorder symptoms include school or work refusal or school or work phobia, resistance to going to bed at night, and physical complaints in reaction to actual or anticipated separation from primary caretakers.
  • Professionals trained and experienced in assessing mental health in children will likely interview the afflicted individual and that person's parents or other loved ones separately and ask about symptoms of anxiety, screen for other mental-health conditions, and recommend that the anxiety sufferer receive a full medical evaluation.
  • Separation anxiety disorder is likely caused by the combination of genetic and environmental vulnerabilities. Risk factors include low socioeconomic status, family histories of anxiety, and mothers who were stressed during pregnancy.
  • A majority of children with separation anxiety disorder have school refusal as a symptom. Up to 80% of children who refuse school qualify for a diagnosis of separation anxiety disorder.
  • Counseling is usually considered the best treatment method compared to medications. Types of counseling used to treat separation anxiety disorder include behavioral, cognitive, and individual psychotherapies, as well as parent counseling and guiding teachers on how to help the person with the disorder.
  • SSRIs like fluvoxamine are considered the safest and most effective medications to treat separation anxiety disorder, followed by tricyclic antidepressants (TCAs), with benzodiazepines as a last resort.
  • People with separation anxiety disorder are at higher risk for developing other mental-health problems, particularly anxiety disorders.
  • Educating parents on ways to help their child cope with anxiety may be helpful in preventing the development of separation anxiety disorder.

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What is separation anxiety disorder?

To understand separation anxiety disorder, it is important to first recognize the normal difficulty that infants and toddlers have with strangers and in separating from parents and caretakers. Infants show stranger anxiety by crying when someone unfamiliar to them approaches. This normal stage of development is connected with the baby learning to distinguish his or her parents or other familiar caretakers from people they don't know. Stranger anxiety usually starts at about 8 months of age and ends by the time the child is 2 years old, according to the American Academy of Pediatrics.

Separation anxiety as a normal life stage first develops at about 7 months of age, once a baby understands that his or her caregivers do not disappear when out of sight (object permanence). That leads to the baby developing a true attachment to those adults. Normal separation anxiety is most commonly at its strongest at 10-18 months of age and gradually subsides, usually by the time the child is 3 years old. Normal separation anxiety may result in parents having trouble with their babies at bedtime or other times of separation, in that the child becomes anxious, cries, or clings to the caretaker.

In addition to the child's temperament, factors that contribute to how quickly or successfully he or she moves past separation anxiety by preschool age include how well the parent and child reunite, the skills the child and adult have at coping with the separation, and how well the adult responds to the infant's separation issues. For example, children of anxious parents tend to be anxious children.

Separation anxiety disorder is a mental health disorder that usually begins in childhood and is characterized by worrying that is out of proportion to the situation of temporarily leaving home or otherwise separating from loved ones. Approximately 4%-5% of children and adolescents suffer from separation anxiety disorder.

What are separation anxiety disorder symptoms and signs?

Symptoms of separation anxiety disorder may include

  • repeated excessive anxiety about something bad happening to loved ones or losing them;
  • heightened concern about either getting lost or being kidnapped;
  • repeated hesitancy or refusal to go to day care or school or to be alone or without loved ones or other adults who are important to the anxious child;
  • persistent reluctance or refusal to go to sleep at night without being physically close to adult loved ones;
  • repeated nightmares about being separated from the people who are important to the sufferer;
  • recurrent physical complaints, such as headaches or stomachaches, when separation either occurs or is expected.

Examples of behavioral symptoms that children may exhibit to express the anxiety, hesitancy, reluctance, or refusal of events that separate them from loved ones include crying, having tantrums, whining, or begging. Examples of physical symptoms that separation anxiety disorder sufferers may have include stomach upset, headaches, and diarrhea. To qualify for the diagnosis of separation anxiety disorder, a minimum of three of the above symptoms must persist for at least a month in children and adolescents and at least six months in adults, and cause significant stress or problems with school, social relationships, or some other area of the sufferer's life. Also, the disorder is not considered to be present if symptoms only take place when the person is suffering from certain other mental-health problems, such as schizophrenia or from a specific kind of developmental disability called pervasive developmental disorder. School refusal, also called school phobia, may be a symptom of separation anxiety disorder, but it can also occur as a symptom of other anxiety disorders and is not a diagnosis by itself.

Social phobia, also an anxiety disorder, differs from separation anxiety disorder in that social phobia is characterized by severe fear of most, if not all, social situations, not just events that result in separating from primary caregivers. This illness affects about 1% of children and adolescents and up to 5% of adults.

Individuals with social phobia may be children, teenagers, or adults, and the anxiety may interfere with the person's ability to function. Children with this problem may have difficulty with a number of ordinary activities, such as playing with their peers, talking in class, or speaking to adults.

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What are causes and risk factors for separation anxiety disorder?

Separation anxiety disorder (as with most mental-health conditions) is likely caused by the combination of genetic and environmental vulnerabilities rather than by any one thing.

In addition to being more common in children with family histories of anxiety, children whose mothers were stressed during pregnancy with them tend to be more at risk for developing this disorder.

A majority of children with separation anxiety disorder have school refusal as a symptom and up to 80% of children who refuse school qualify for the diagnosis of separation anxiety disorder. Approximately 50%-75% of children who suffer from this disorder come from homes of low socioeconomic status.

How is separation anxiety disorder diagnosed?

Health-care professionals who have training and experience understanding symptoms of children and adolescents are usually the most qualified to assess separation anxiety disorder. The assessment most often involves a pediatrician and child psychologist, child psychiatrist, or other mental-health professional interviewing both the child and his or her parent(s) when assessing separation anxiety disorder. Those interviews often take place separately to allow everyone to speak freely. This is particularly important given how differently children and their parents may see the situation and how difficult it can be for children to hear their problems discussed. In addition to asking about specific symptoms of anxiety, the professional will likely explore whether the child has symptoms of any other mental-health issues and will recommend that the child receive a full physical examination and lab work to ensure that there is no medical reason for the issues the child is experiencing.

What is the treatment for separation anxiety disorder?

Counseling, rather than medication, is the treatment of choice for separation anxiety disorder that is mild in severity. For children who either have not improved with counseling alone, suffer from more severe symptoms, have other emotional problems in addition to separation disorder, treatment should consist of a combination of approaches. Psychotherapy, medication, and parent counseling are three interventions that have been found to be effective for the treatment of separation anxiety disorder, particularly in combination.

Behavioral modification therapy is an intervention that directly addresses the behavioral symptoms of separation anxiety disorder. This intervention tends to be more effective and less burdensome to the child if behaviors are addressed positively rather than negatively. The child is not usually punished for continuing to suffer from symptoms but rewarded for small victories over symptoms. For example, instead of withholding dessert from a preschooler who refuses to go into her room for bedtime, give hugs and praise for the child when she can go near her room at first, followed by being able to go in and stay for five minutes, increasing the length of time she needs to be in her room before being praised. Even if she needs significant parental support at first (for example, sitting in the room with her on the parent's lap, then next to her, then just outside the room after she becomes comfortable with each step), this approach allows the child to feel a sense of success at every step and build on it rather than experiencing a sense of failure, which tends to lower the child's likelihood of being able to overcome her anxiety. The implementation of behavioral therapy generally involves the practitioner providing parenting tips to the child's caregivers, regular meetings with the child, and may include guidance to teachers on how to help alleviate the child's anxiety.

Cognitive therapy is used to help children learn how they think and increase their ability to solve problems and focus on the positive things that are going on, even in the midst of their anxiety. By learning to focus on more positive thoughts and feelings, children may become more open to learning strategies to deal with anxiety, such as playing games, coloring, watching television, or listening to music. Although formal relaxation techniques such as imagining themselves in a relaxing situation may be considered more appropriate interventions for older children, adolescents, and adults, even toddlers can be taught simple relaxation techniques, such as imitating their parents, taking deep breaths, or slowly counting to 10 as ways of calming themselves.

If psychotherapy is unsuccessful or if the children's symptoms are so severe that they are nearly incapacitating, medication is considered a viable option. However, there are no medications specifically approved by the U.S. Food and Drug Administration (FDA) to treat separation anxiety disorder. Selective serotonin reuptake inhibitors (SSRIs) such as fluvoxamine (Luvox) have been found to be an effective treatment for separation anxiety disorder.

SSRIs are medications that increase the amount of the neurochemical serotonin in the brain. These medications work by selectively inhibiting (blocking) serotonin reuptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) are connected to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neuron to another.

The SSRIs work by keeping serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. It is thought that this, in turn, helps arouse (activate) cells that have been deactivated by anxiety, thereby relieving a child's anxiety symptoms.

SSRIs have fewer side effects than the tricyclic antidepressants (TCAs). These medications do not tend to cause orthostatic hypotension (a sudden drop in blood pressure when sitting up or standing) or heart rhythm disturbances, like the TCAs. Therefore, SSRIs are often the first-line medication treatment for separation anxiety disorder. Examples of SSRIs include

SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. Side effects generally go away within the first month of SSRI use. Some patients experience tremors with SSRIs. The serotonin syndrome (also called serotonergic [caused by serotonin] syndrome) is a serious neurologic condition associated with the use of SSRIs, characterized by high fevers, seizures, and heart rhythm disturbances. There has also been heightened concern that children and adolescents are at increased risk of having the rare reaction of feeling acutely (suddenly and significantly) more anxious or newly depressed, even to the point of wanting, planning, attempting or in extremely rare cases, completing suicide or homicide. Serotonin syndrome, as well as acute worsening of emotional symptoms, is very rare.

All people are unique biochemically so the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean another medication in this group will not be beneficial. However, if someone in the patient's family had a positive response to a particular drug, that drug may be preferable to try first. Medications that are sometimes considered in treating separation anxiety disorder when SSRIs either don't work or are poorly tolerated include tricyclic antidepressants (TCAs) and benzodiazepines. These medications were developed in the 1950s and 1960s to treat depression. TCAs work mainly by increasing the level of norepinephrine in the brain synapses, although they also may affect serotonin levels. Examples of tricyclic antidepressants include

TCAs are generally safe and well tolerated when properly prescribed and administered. Overdose of TCAs can cause life-threatening heart rhythm disturbances. Rarely, this can occur even if an overdose is not taken. Some TCAs can also have anticholinergic side effects, which are due to the blocking of the activity of the nerves that are responsible for control of the heart rate, gut motion, visual focus, and saliva production. Thus, some TCAs can produce dry mouth, blurred vision, constipation, and dizziness upon standing. The dizziness results from low blood pressure. TCAs should also be avoided in patients with seizure disorders or a history of strokes.

Benzodiazepines tend to be the least-prescribed group of medications to children suffering from separation anxiety disorder. This group of medications is thought to work by increasing the activity of calming chemicals in the brain. Benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), and alprazolam (Xanax). Unfortunately, there is a possible risk of the child becoming dependent on benzodiazepines. These medications tend to only be used as a last resort, when the child has had unsuccessful trials of the other two classes of medications or suffers from incapacitating symptoms of anxiety.

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What happens if separation anxiety disorder is left untreated?

Potential complications of separation anxiety disorder include depression and anxiety problems as adults, as well as personality disorders, in which anxiety is a major symptom. Adults with separation anxiety disorder have a guarded prognosis due to their being at risk of being quite emotionally disabled.

Is it possible to prevent separation anxiety disorder?

Research indicates that educating parents on ways to help their child cope with anxiety may be helpful in the prevention of separation anxiety disorder. Specifically, helping parents guide their child through experiences that cause anxiety, as well as developing healthy ways to cope with such experiences, seems to decrease the likelihood of developing any anxiety disorder, including separation anxiety disorder.

Where can I find more information on separation anxiety disorder?

American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue NW
Washington, DC 20016
Phone: 202-966-7300
Fax: 202-966-2891
http://www.aacap.org

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
Phone: 847-434-4000
Fax: 847-434-8000
Email: kidsdocs@aap.org
http://www.aap.org

Anxiety Disorders Association of America (ADAA)
8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
Phone: 240-485-1001
Fax: 240-485-1035
Email: information@adaa.org
http://www.adaa.org

National Institute of Mental Health (NIMH), Public Information & Communication Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
Toll Free: 1-866-615-6464
TTY: 301-443-8431
TTY Toll Free: 1-866-415-8051
Fax: 301-443-4279
Email: nimhinfo@nih.gov
http://www.nimh.nih.gov

Medically reviewed by Margaret Walsh, MD; American Board of Pediatrics

REFERENCES:

American Academy of Child and Adolescent Psychiatry. "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders." Journal of the American Academy of Child and Adolescent Psychiatry 46.2 (2007): 267-283.

American Academy of Pediatrics. "Separation Anxiety Disorder: Planning Treatment." Pediatrics in Review 21 (2000): 248.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association, 2000.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

den Boer, J.A. "Social Phobia: Epidemiology, Recognition and Treatment." British Medical Journal 315 (1997): 796-800.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. American Psychiatric Association: Washington, D.C., 2000.

Foley, D.L., D.B. Goldston, E.J. Costello, and A. Angold. "Proximal Psychiatric Risk Factors for Suicidality in Youth." Archives of General Psychiatry 63 (2006): 1017-1024.

Foley, D., M. Rutter, A. Pickles, A. Angold, M. Hermine, J. Silberg, and L. Eaves. "Informant Disagreement for Separation Anxiety Disorder." Journal of the American Academy of Child and Adolescent Psychiatry 43.4 Apr. 2004: 452-460.

Fremont, W.P. "School Refusal in Children and Adolescents." American Family Physician Oct. 15, 2003.

Lewinsohn, P.M., J.M. Holm-Denoma, J.W. Small, J.R. Seeley, and T.E. Joiner. "Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness." Journal of the American Academy of Child and Adolescent Psychiatry 47.5 May 2008: 548-555.

Masi, G., M. Mucci, and S. Millepiedi. "Separation Anxiety Disorder in Children and Adolescents: Epidemiology, Diagnosis and Management." CNS Drugs 15.2 (2001): 93-104.

National Institute of Mental Health. "Behavioral Therapy Effectively Treats Children With Social Phobia." Dec. 17, 2007.

Osone, A., and S. Takahashi. "Possible Link Between Childhood Separation Anxiety and Adulthood Personality Disorder in Patients With Anxiety Disorders in Japan." Journal of Clinical Psychiatry 67.9 Sept. 2006: 1451-1457.

Physicians' Desk Reference Staff. Physicians' Desk Reference, 62 ed. Blackwell Publishing: Oxford, United Kingdom, 2008.

Rapee, R.M., S. Kennedy, M. Ingram, et al. "Is prevention of and early intervention for anxiety disorders possible?" Journal of Consultation Clinical Psychology 73 (2005): 488-497.

Silove, D.M., C.L. Marnane, R. Wagner, et al. "The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic." BMC Psychiatry 10 (2010): 21.

Talge, N.M., C. Neal, and V. Glover. "Antenatal Maternal Stress and Long-Term Effects on Child Neurodevelopment: How and Why?" Journal of Child Psychology and Psychiatry 48.3-4 Mar. 7, 2007: 245-261.

van der Linden, G.J., D.J. Stein, and A.J. van Balkom. "The Efficacy of the Selective Serotonin Reuptake Inhibitors for Social Anxiety Disorder (Social Phobia): A Meta-Analysis of Randomized Controlled Trials." International Clinical Psychopharmacology 15.2 Aug. 2000: S15-S23.

Walkup, J.T., M.J. Labellarte, M.A. Riddle, D.S. Pine, L. Greenhill, R. Klein, et al. "Fluvoxamine for the Treatment of Anxiety Disorders in Children and Adolescents." New England Journal of Medicine 344.17 Apr. 26, 2001: 1279-1285.

Last Editorial Review: 8/24/2016

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Reviewed on 8/24/2016
References
Medically reviewed by Margaret Walsh, MD; American Board of Pediatrics

REFERENCES:

American Academy of Child and Adolescent Psychiatry. "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders." Journal of the American Academy of Child and Adolescent Psychiatry 46.2 (2007): 267-283.

American Academy of Pediatrics. "Separation Anxiety Disorder: Planning Treatment." Pediatrics in Review 21 (2000): 248.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association, 2000.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

den Boer, J.A. "Social Phobia: Epidemiology, Recognition and Treatment." British Medical Journal 315 (1997): 796-800.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. American Psychiatric Association: Washington, D.C., 2000.

Foley, D.L., D.B. Goldston, E.J. Costello, and A. Angold. "Proximal Psychiatric Risk Factors for Suicidality in Youth." Archives of General Psychiatry 63 (2006): 1017-1024.

Foley, D., M. Rutter, A. Pickles, A. Angold, M. Hermine, J. Silberg, and L. Eaves. "Informant Disagreement for Separation Anxiety Disorder." Journal of the American Academy of Child and Adolescent Psychiatry 43.4 Apr. 2004: 452-460.

Fremont, W.P. "School Refusal in Children and Adolescents." American Family Physician Oct. 15, 2003.

Lewinsohn, P.M., J.M. Holm-Denoma, J.W. Small, J.R. Seeley, and T.E. Joiner. "Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness." Journal of the American Academy of Child and Adolescent Psychiatry 47.5 May 2008: 548-555.

Masi, G., M. Mucci, and S. Millepiedi. "Separation Anxiety Disorder in Children and Adolescents: Epidemiology, Diagnosis and Management." CNS Drugs 15.2 (2001): 93-104.

National Institute of Mental Health. "Behavioral Therapy Effectively Treats Children With Social Phobia." Dec. 17, 2007.

Osone, A., and S. Takahashi. "Possible Link Between Childhood Separation Anxiety and Adulthood Personality Disorder in Patients With Anxiety Disorders in Japan." Journal of Clinical Psychiatry 67.9 Sept. 2006: 1451-1457.

Physicians' Desk Reference Staff. Physicians' Desk Reference, 62 ed. Blackwell Publishing: Oxford, United Kingdom, 2008.

Rapee, R.M., S. Kennedy, M. Ingram, et al. "Is prevention of and early intervention for anxiety disorders possible?" Journal of Consultation Clinical Psychology 73 (2005): 488-497.

Silove, D.M., C.L. Marnane, R. Wagner, et al. "The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic." BMC Psychiatry 10 (2010): 21.

Talge, N.M., C. Neal, and V. Glover. "Antenatal Maternal Stress and Long-Term Effects on Child Neurodevelopment: How and Why?" Journal of Child Psychology and Psychiatry 48.3-4 Mar. 7, 2007: 245-261.

van der Linden, G.J., D.J. Stein, and A.J. van Balkom. "The Efficacy of the Selective Serotonin Reuptake Inhibitors for Social Anxiety Disorder (Social Phobia): A Meta-Analysis of Randomized Controlled Trials." International Clinical Psychopharmacology 15.2 Aug. 2000: S15-S23.

Walkup, J.T., M.J. Labellarte, M.A. Riddle, D.S. Pine, L. Greenhill, R. Klein, et al. "Fluvoxamine for the Treatment of Anxiety Disorders in Children and Adolescents." New England Journal of Medicine 344.17 Apr. 26, 2001: 1279-1285.

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