separation anxiety thesis

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Separation anxiety disorder.

Joshua Feriante ; Tyler J. Torrico ; Bettina Bernstein .

Affiliations

Last Update: February 26, 2023 .

• Continuing Education Activity

Separation anxiety disorder (SAD) is one of the most common childhood anxiety disorders. SAD is an exaggeration of otherwise developmentally typical anxiety manifested by excessive concern, worry, and even dread of the actual or anticipated separation from an attachment figure. Although separation anxiety is a developmentally appropriate phenomenon, the disorder manifests with improper intensity at an inappropriate age or in an inappropriate context. Developmentally appropriate separation anxiety manifests between the ages of 6 to 12 months. This normative or physiological separation anxiety remains steadily observable until approximately age 3 and, under normal circumstances, diminishes afterward. This activity outlines the current DSM-5-TR diagnostic criteria; available validated assessment tools; evidence-based treatments, often combination treatment approaches; and the benefits of interprofessional team collaboration to enhance clinical outcomes for patients with separation anxiety disorder.

• Recognize the current DSM-5-TR diagnostic criteria for separation anxiety disorder.
• Implement validated assessment tools for the diagnosis of separation anxiety disorder.
• Select effective evidence-based treatment modalities for patients diagnosed with separation anxiety disorder.
• Collaborate with the interprofessional team to enhance clinical outcomes for patients with separation anxiety disorder.
• Introduction

Anxiety describes an uncomfortable emotional state characterized by inner turmoil and dread over anticipated future events. Anxiety is closely related and overlaps with fear, a response to perceived and actual threats. Anxiety often results in nervousness, rumination, pacing, and somatization. Every human experiences anxiety because it is an evolved behavioral response to prepare an individual to detect and deal with threats. [1]  Anxiety becomes pathological when it is so overwhelming that there is persistent distress, a decrease in quality of life, and impairment in regular major life activities. [2]

Anxiety disorders are the most common psychiatric disorders in children and are often underrecognized. [3]  Untreated anxiety disorders in children can significantly impair quality of life, lead to comorbid psychiatric conditions, and interfere with social, emotional, and academic development. [4] [5] Adults with anxiety similarly experience poorer quality of life than those without anxiety disorders, and the severity of anxiety can impact daily functioning. [6]

Separation anxiety disorder (SAD) is one of the most common childhood anxiety disorders. SAD involves significant distress when the child is unexpectantly separated from home or a close attachment figure. [7]  SAD is an exaggeration of otherwise developmentally normal anxiety and manifests as excessive concerns, worry, and even dread of the actual or anticipated separation from an attachment figure or home. 

Although separation anxiety is a developmentally appropriate phenomenon, the disorder manifests with improper intensity at an inappropriate age or in an inappropriate context. The  Diagnostic and Statistical Manual of Mental Disorders  (DSM), edition 4, limited the diagnosis of SAD to children and adolescents. However, in the  Diagnostic and Statistical Manual of Mental Disorders , edition 5 (DSM-5), the diagnosis was extended to include adults first diagnosed with SAD in adulthood. [7] One difference in children diagnosed with separation anxiety compared to adults is the type of attachment figures involved. In the case of children, the attachment figures are usually adults, such as parents, whereas adults experience anxiety due to actual or anticipated separation from children, spouses, or romantic partners. [8]

Developmentally appropriate separation anxiety manifests between 6 to 12 months of age. This normative or physiological separation anxiety remains steadily observable until approximately age 3 and, under normal circumstances, diminishes afterward. Developmentally appropriate separation anxiety eventually extinguishes as a child develops a greater sense of autonomy, cognitive ability, and an understanding that a separated attachment figure will return. [9]

More significant than expected duration or intensity of separation anxiety symptoms in children or the development of this disorder in older children, adolescents, or adults constitutes SAD. This disorder severely affects the quality of life and functioning across several areas, including school, work, social interactions, and close relationships. SAD is a gateway anxiety disorder that can lead to poor mental and physical health outcomes, including excessive worry, sleep disturbances, undue distress in social settings, poor academic performance, and somatic complaints. [9]  

The etiology of most psychiatric conditions involves various degrees and types of biological, psychological, and social contributors. Although psychological factors particularly impact the development of anxiety disorders, there are multiple biological components to pathological anxiety. The study of inheritance patterns has revealed a general familial aggregation among major anxiety disorders. [10]  Twin studies have demonstrated stronger inheritance patterns for monozygotic twins than dizygotic twins, suggesting a genetic component to the development of pathological anxiety. [11]  Although the study of anxiety and gene-environment interactions is limited, it is known that epigenetic mechanisms, particularly DNA methylation, contribute to mediating transcription factors for stress-related genes, which may underlie the development of pathological anxiety. [12]

Behavioral scientists have contributed significantly to uncovering the psychological mechanisms contributing to anxiety, specifically separation anxiety. Conditioned responses of learned fear are more significant among anxiety-disordered individuals compared to controls, with an explanation of 2 likely mechanisms: first, there is greater excitatory conditioning to danger cues, and second, there is impaired inhibitory conditioning to safety signals. [13]

Attachment theory describes a child's requirement to develop a relationship with a caregiver for normal social and emotional development. In attachment theory, there are 4 main attachment styles: secure attachment, anxious-avoidant attachment, disorganized attachment, and anxious-ambivalent attachment. Anxious-ambivalent attachment is the most common attachment style for those with SAD. A common symptom of anxious-ambivalent attachment is anxiety when the caregiver is absent and limited relief when the caregiver reappears. [14]

Evolutionarily, normal separation anxiety likely provided survival benefits given the human species' altriciality. [15]  Separation anxiety is a universal phase of human development that typically emerges at or before 1 year of age, peaks between 9 to 18 months, and phases out by approximately 2.5 years. The re-emergence of transient separation anxiety is common in children when they enter school for the first time, which may be considered a normal response. However, conditioning this response can lead to the development of SAD, particularly when conditioned over multiple weeks. [13]  

Parenting behaviors implicate cross-generational influences on the development of childhood anxiety. These parenting behavioral systems include vicarious learning, social referencing, and modeling of parental anxiety. Further, overly protective and overly critical parenting styles, parental response to child anxiety, and family accommodation of a child's anxiety all contribute to the conditioning and development of childhood anxiety. [16] Children of parents who suffer from depression and anxiety disorders are at a higher risk of developing a depressive or anxiety disorder. [17]

• Epidemiology

Anxiety disorders are among the most common pediatric mental health disorders, with an estimated prevalence of 5 to 25% worldwide. [18]  SAD is the most frequently diagnosed childhood anxiety disorder, said to account for 50% of the referrals for anxiety-related mental health treatment. [18]  The prevalence of SAD is estimated at 4% in population-based studies, with an increase to 7.6% in pediatric clinical samples. [9]  Clinical data suggests that 4.1% of children will exhibit a clinical level of separation anxiety, with approximately one-third persisting into adulthood if left untreated. [18]  

The average onset age is approximately 6 years, making it one of the earliest anxiety disorders to present in children. [9]  In a United States-based study, SAD was found to have the highest lifetime prevalence at 6.7% of all anxiety disorders when specific and social phobias are excluded. [19]  The lifetime prevalence of adult SAD is 6.6%, with 77.5% of the patients reporting onset in adulthood. [8]

• Pathophysiology

Neuroanatomically, the amygdala is classically associated with provoking a fear response when stimulated. The amygdala and other fear-related neurocircuitry may share a similar neuroanatomy to anxiety neurocircuitry. [20] The amygdala and its connections to the frontal cortex (perirhinal cortex, ventrolateral prefrontal cortex, anterior insula) have received the most attention. [21] As the amygdala is part of the limbic system, other limbic system structures likely contribute to the development of anxiety, with a specific interest in the hippocampus as it plays an integral role in fear learning and extinction. [22] Functional magnetic resonance imaging (fMRI) studies have found that hypofunction of the prefrontal cortex and anterior cingulate cortex is associated with emotional dysregulation and cognitive dysfunction in those with anxiety. [23]

The activation of fear neurocircuitry, with presumed anxiety neurocircuitry overlap, involves the release of various neurochemicals that lead to sympathetic stimulation. Classically characterized as a "fight-or-flight" reaction, this sympathetic response evolved to be adaptive and for a prompt behavioral response to avoid actual or perceived danger. [1] However, this response can be conditioned to over-activate, leading to pathological anxiety even when exposure to threat is low or should be low. [13]  The neurochemicals involved in producing a fight-or-flight response are many and include norepinephrine, epinephrine, cortisol, neurosteroids, and vasopressin. [24] Dopamine likely has a modulatory role in producing anxiety-like behavior. [25]  Low activity of postsynaptic serotonin 5-HT1A receptors contributes to pathological anxiety, which has led to the development of pharmacotherapy attempting to modulate these receptors to reduce anxiety. [26]

• History and Physical

A child's caregiver generally prompts the exploration of potential SAD because the child is "inseparable," causing interference with a major life activity of either the caregiver or the child. Investigating the impact of the child's behavior on the major life activity (ie, school or home life) can be used to obtain information on where symptoms most often occur and their severity. Academic performance is the life activity most frequently impacted by childhood SAD. If SAD is not the primary concern of the caregiver, it is still essential to investigate the child's academic performance. [27] Inquiring about all settings where separation anxiety occurs, age at symptom onset, and if symptoms worsen in any specific situation is essential. Caregivers should also be asked whether or not the child has verbalized catastrophization, including extreme fear that they may be kidnapped or seriously hurt in the caregiver's absence or if the caregiver will have a serious illness, injury, or death in the child's absence. [27] [28]

Obtaining a developmental and social history can clarify the diagnostic picture by providing context for the patient's risk factors for SAD. Inquiry into the child's living situation and relationship with his caregiver(s) can provide perspective if the patient experienced caregiver instability in early life and ultimately provide clues for the attachment style the child has developed with his current caregiver(s). [27]  Obtaining a trauma history for the patient and caregiver to screen for sexual and physical abuse is essential, particularly if the child may have experienced an adverse event in the absence of a caregiver and fears this recurring. Although SAD is commonly a first-lifetime psychiatric illness, screening for past psychiatric history remains essential, mainly as children's anxiety disorders are often comorbid. [27]  

Obtaining a family psychiatric history may reveal a parent or caregiver with an anxiety disorder, which poses genetic loading and may be a source of behavioral modeling for the child to learn anxious behaviors. Developmental history can reveal whether or not the patient is currently at a developmentally appropriate stage for their age. If the patient is developmentally delayed, an in-utero and birth history should be obtained when possible. The patient's medical history can help differentiate between real physical pain and somatization from severe anxiety. Finally, when appropriate, interviewing the child alone may reveal first-hand the symptoms the child experiences. [27] [28]

When interviewing an adult with potential SAD, understanding who the adult patient has difficulty separating from is a good starting point. If the patient has difficulty separating from a romantic partner, obtaining a history of the patient's dating history can be revealing. [29] [30]  Although important, caution should be used when obtaining a trauma history. Patients may find it difficult to speak about past physical and sexual abuse, particularly if it was from a past or current romantic partner. When appropriate and with patient consent, obtaining collateral information from the individual the patient has difficulty separating from can give more perspective on symptom severity. [8]

The mental status examination is completed in psychiatric evaluations and has a variable presentation in SAD, but the following areas should be carefully considered:

• Behavior: How does the patient's behavior change when united and separated from their caregiver? Does the patient have anxious behaviors, such as constant movement, shaking, and small tremors? Are there clinging behaviors, such as requiring physical contact with the caregiver? 
• Speech: Is the patient's tone frightened when speaking about being separated from the caregiver? Does the patient ask for permission from the caregiver to speak?
• Affect: Is the patient always anxious or relieved when physically close to the caregiver?
• Thought content: Is catastrophization present (ie, thoughts of dying or the caretaker passing if separation is forced)? 
• Impulse control: Impulse control is expected to be poor for individuals with SAD.
• Insight: Insight for children is likely to be poor, but adults with SAD may be able to understand that their behaviors are maladaptive, and this should be assessed individually.

The transient re-appearance of separation anxiety when children first attend school is crucial in predicting the normal remission of separation anxiety versus the development of SAD. [13]  Physical separation for children from parents to participate in academic settings is the most common prompt for identifying SAD. School functioning is generally significantly impaired by SAD, as many children may demonstrate disruptive behaviors until reunited with their caregiver or refuse to attend school altogether. An estimated 75% of children suffering from SAD have school-refusal behaviors. [18]  These behaviors are variable but can include refusal to enter the school building once arrived, physically clinging to a parent, screaming when attempting to be separated, and vocalizing somatic symptoms such as a headache, "stomach ache," or other types of illness. [18]  

Due to the severity of separation anxiety, children may fall behind in coursework or have significant absence that impairs their ability to progress appropriately in school. Additionally, they may become isolated from school peers, and conflict may develop in the family if parents become frustrated by their child's condition. [18] [31]

Separation anxiety can additionally occur in the home setting. Common manifestations at home include a child being afraid to be in a room alone, refusing to sleep alone, and shadowing or clinging to the caregiver's side. When the child is separated from the caregiver, similar severe anxiety can occur, including crying and screaming. These symptoms can become a significant burden for the caregiver, who may feel suffocated by their child's extreme demands for attention and decreased privacy. [18] [31]

Another common SAD symptom is the pervasive worry that harm will come to the caregiver if separated, leading to severe distress and nightmares. Similarly, the child may worry about becoming lost, kidnapped, or having an accident if separated from their caregiver. [18] [31]  When children are distraught and have a forced separation, they may show aggression toward the person separating them from their caregiver. When physically separated, adults with SAD will likely resort to calling, texting, or using other technological means to communicate with their attached figure. Often, the person suffering from SAD is perceived as having excessive demands and can be a source of frustration for family members or the caregiver, leading to further resentment and familial conflict, perpetuating the course of the condition. [8]

Individuals with suspected SAD should be referred for a psychiatric evaluation, and if available, evaluation by a child and adolescent psychiatrist is optimal. The initial goals are to develop rapport with the patient, obtain historical information in detail from the patient and affected caregiver(s), and conduct a mental status examination. Evaluation for applicable DSM-5-TR diagnostic criteria should be performed to make a formal diagnosis. 

Separation Anxiety Disorder DSM-5-TR Criteria

1. Developmentally inappropriate and excessive anxiety when separated from whom the individual is attached, evidenced by at least 3 of the following:

• Recurrent excessive distress with actual or anticipated separation from home or attachment figure(s)
• Persistent and pervasive worry about losing the attachment figure(s) or possible harm befalling them, such as illness, injury, disasters, or death
• Persistent and pervasive worry that an untoward event will be experienced by the patient and lead to prolonged or permanent separation
• Reluctance or refusal to go out, such as to school or work, because of fear of separation
• Refusal to be alone at home or in other settings
• Refusal to sleep without being near the attachment figure(s)
• Repeated nightmares about separation
• Repeated physical symptoms when separation occurs or is anticipated [8]

2. The symptoms must last at least 4 weeks in children and adolescents but typically occur for 6 months or more in adults.

3. The disturbance causes clinically significant impairment in a major life function (ie, academic or occupational functions).

4. The symptoms are not better explained by another psychiatric condition.

Screening Tools

Multiple screening tools for anxiety disorders in children exist and have wide availability and validation. When there is difficulty in obtaining the full diagnostic criteria from the interview alone, implementing a validated screening tool can be helpful in the diagnosis of SAD and in identifying possible comorbid conditions. 

Screen for Child Anxiety-Related Emotional Disorders (SCARED):  SCARED is one of the most commonly used assessment tools for diagnosing anxiety disorders in children. SCARED is a child and parent self-report measure evaluated in numerous settings worldwide. [32]  Various versions/revisions of the questionnaire have been developed. The most commonly used version consists of 41 questions. The total score is based on 5 subscale scores for the most common pediatric anxiety disorders: generalized anxiety disorder, social phobia, SAD, somatic symptoms/panic disorder, and school phobia. Each response is scored between 0 and 2, with a total score of 25 or higher having high sensitivity and specificity for discriminating between anxiety and non-anxiety disorders. [32]  A 55% or higher reduction in the total score with treatment best predicts treatment response, and a 60% or higher reduction in SCARED-parent scores predicts remission. [32]  

The SCARED assessment tool can be used free of charge with an acceptable time burden on clinicians and families, making it an excellent tool for diagnosing and managing anxiety disorders in children. SCARED cutoffs can also be used to guide treatment. For example, an insufficient reduction in the SCARED score after an adequate trial of behavioral therapy may indicate the need for pharmacotherapy. [32]  Studies have shown some discordance in the information provided by the child and parent on this questionnaire without apparent contributory factors. [33]  More research is warranted to understand the cause of "low informant agreement" and what factors contribute to this discrepancy. Still, the SCARED assessment tool is considered a stable, reliable, valid, and sensitive measure of anxiety, despite the informant discrepancy, which interestingly also stays stable over time. [33]  The SCARED screening tool has shown strict measurement invariance and solid test-retest reliability.

Separation Anxiety Avoidance Inventory (SAAI):  SAAI is specifically designed to aid in diagnosing SAD. The SAAI child (SAAI-C) and parent (SAAI-P) versions have demonstrated good internal consistency, test-retest reliability, and construct and discriminant validity. [34]  This assessment tool was also shown to be sensitive to treatment change with a substantial parent-child agreement. SAAI is a self-report questionnaire designed to assess the avoidance of 7 separation situations (when age-inappropriate questions are excluded). The severity of the avoidant behavior is rated on a scale of 0 to 4. [34]  The disadvantage of SAAI is that it focuses exclusively on avoidance behaviors and neglects subjective aspects of worry and distress, which are core features of SAD. [35]  

Children's Separation Anxiety Scale (CSAS):  The CSAS consists of 20 items grouped into 4 factors:

• Worry about separation
• Distress about separation
• Opposition to separation
• Calm at separation

The unique feature of this tool is the presence of a positive factor, "calm at separation." Validation studies report good internal consistency with good temporal stability and test-retest reliability. [35]  The validation study reports that it is a reliable indicator of anxiety and differentiates anxiety symptoms from those of depression in children. [35]  The authors also state that finding a weak relation with trait anger and no correlation with state anger supports the discriminant validity of the CSAS. [35]  This study only analyzed child-reported surveys; the psychometric properties of the CSAS with clinical samples and validation of the parent version are still lacking.

Youth Anxiety Measure (YAM): YAM is a new parent-child questionnaire developed to assess anxiety disorder symptoms in children and adolescents according to the DSM-5. The scale consists of 2 parts: part I consists of 28 items and measures the major anxiety disorders, including SAD, and part II contains 22 items relating to specific phobias and agoraphobia. [36]  The validation study for this questionnaire reports acceptable "face validity" with items successfully linked to the intended anxiety disorders and phobias. The authors report good internal consistency and reliability of the new measure with the parent-child agreement and concurrent, convergent, divergent, and discriminant validity. [36]  An analysis of the psychometric qualities of the scale with the collection of normative data in non-clinical and clinical populations is still needed.

Anxiety Disorder Interview Schedule (ADIS):  ADIS is a well-validated diagnostic interview suitable for measuring all anxiety disorders, mood disorders, and attention-deficit/hyperactivity disorder in children. [37]  The ADIS is a semi-structured diagnostic interview that primarily assesses child anxiety disorders, and the diagnoses are derived from interviews with both the child and the parent. [38]  The interviews cover the entire range of anxiety-related disorders outlined by the DSM-5. Each diagnosis is assigned a clinician severity rating (CSR), a symptoms severity rating, and a functional impairment rating. A CSR of 4 or higher is required to provide a particular diagnosis. If the child and parent interviews yield different diagnoses and CSRs, the interviewer makes a composite diagnosis using recommended guidelines in the clinician manual. The ADIS's parent and child versions possess high inter-rater and test-retest reliability. One study reported almost perfect agreement on both the child and parent interview for diagnosing an anxiety disorder using ADIS. They also report almost perfect agreement regarding the severity of the primary diagnosis. [37]  The ADIS is considered the gold-standard diagnostic evaluation for anxiety disorders. 

Pediatric Anxiety Rating Scale (PARS):  PARS is a clinician-rated scale of anxiety severity using the frequency of distress symptoms, avoidance behaviors, and interference in daily functioning. [39]  In a multisite study evaluating 128 children aged 6 to 17, PARS was shown to have high inter-rater reliability, adequate test-retest reliability, and fair internal consistency. [39]  PARS scores are sensitive to treatment and parallel change in other measures of anxiety symptoms. This assessment tool has been validated in various populations and is frequently used worldwide in clinical and research settings. [40]

• Treatment / Management

Appropriate treatment and management of SAD often depend on the symptom severity. In the case of mild symptoms, patient and parent education, support, and encouragement may be sufficient to help the patient resume normal activities. [41]  Maintaining regular eating, sleeping, and exercise schedules with removing inconsistent routines should be encouraged. Anxiety symptoms should be reassessed with validated screening tools to monitor for changes. [41]  When treatment is required, the recommended first-line therapy is cognitive behavioral therapy. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed and are known to be successful at managing anxiety disorders; however, there are no medications with an FDA-labeled indication for SAD. [41]  

Cognitive Behavioral Therapy (CBT)

CBT is considered the first-line treatment for SAD and is an optimal choice for its efficacy and low risk of adverse effects. CBT should include techniques involving psychoeducation, changing maladaptive thought patterns, and gradual exposure to anxiety-provoking situations. Effective CBT typically requires 10 to 15 outpatient sessions (60-90 minutes each) with the practice of newly acquired skills at home. The treatment regime may be shortened or prolonged depending on the severity of symptoms and comorbid factors. [41]  Notably, up to 44% of the pediatric population treated with CBT for anxiety disorders do not improve. [42]

Exposure therapy effectiveness is postulated to help increase the treatment response rate. Subjective reporting and heart rate measurements are unreliable indices of distress or emotional arousal during exposure. A reliable and alternate method of accurately measuring distress during exposure therapy is electrodermal activity (EDA). EDA is specific to sympathetic arousal and measures the activity of the eccrine sweat glands. Higher EDA indicates greater emotional and physiological arousal. [42]  Physiological arousal during exposure therapy is the strongest predictor of treatment response. Physiological arousal negatively predicts the response rate, with one study reporting that high physiological arousal predicted poorer treatment response to brief CBT. [42]  

Combination Therapy with CBT and an SSRI

Although various reports describe improvement in SAD with pharmacotherapy, there are no medications with FDA-labeled indications to treat SAD, and high-quality (double-blind, placebo-controlled) studies are lacking. Some studies report CBT and SSRIs as equally efficacious for children with anxiety disorders; others report CBT to be superior to pharmacotherapy on some indices. More recent data suggest that combination treatment with CBT and SSRIs is more efficacious than either treatment alone, with as many as 81% of children with anxiety disorders who received sertraline and CBT being classified as responders compared to a 60% response rate for CBT alone and 55% response rate for sertraline alone. [41]  Interestingly, patients receiving placebo pharmacotherapy had a 23% response rate. [41]

A randomized control trial published in 2008 reported the superiority of combination CBT and SSRI therapy, attributed to the synergistic effects of the 2 therapies. [43]  The study included children with moderate-to-severe anxiety and did not report any significant adverse effects using SSRIs. They concluded that CBT and sertraline, either in combination or as monotherapy, were effective for treating childhood anxiety disorders, including SAD; however, combination therapy was superior to either alone. [43]

Authors of a recent systematic review evaluating the comparative effectiveness and safety of CBT and various pharmacotherapies for childhood anxiety disorders reported that SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) improved anxiety symptoms when compared to placebo. The efficacy of benzodiazepines and tricyclic antidepressants (TCAs) was supported by insufficient or low-quality evidence for treating these disorders. [44]  Benzodiazepines and TCAs are, therefore, not recommended for the management of childhood anxiety disorders. [45]

• Differential Diagnosis

The correct identification of the anxiety-inducing stressor is necessary to make an accurate diagnosis. In the case of SAD, the primary stressor is the patient being away from their attachment figure. The associated anxiety may manifest similarly to other anxiety disorders, which include generalized anxiety disorder, social anxiety disorder, specific phobia, and panic disorder. In addition, patients may present with multiple anxiety disorders. To assist with accurate diagnosis in children, using SCARED is recommended for assessment as it can differentiate various anxiety disorders from others. [46]  Adults with SAD may have symptoms and traits related to borderline personality disorder, including fears of abandonment, anxiousness, and separation insecurity. [47]

A longitudinal study surveying anxiety symptoms in 242 participants with a mean age of 10 years found that 56% had an elevated SCARED score at 1-year follow-up and 32% had elevated scores at 3-year follow up. Eight percent of the participants in this study had a fluctuating course. [48]  

Most studies report that anxiety disorders tend to have a chronic and unremitting course if left untreated. [41]  With treatment, childhood anxiety disorders are believed to have a good prognosis [43] , but long-term longitudinal data supporting this claim is limited. [49]  A 4-year study evaluating adolescents and young adults with childhood anxiety disorders reported that only 21.7% of the patients were in stable remission, 48% relapsed, and 30% were "chronically ill" at the 4-year mark. The assigned treatment in the study (SSRI, CBT, SSRI plus CBT, or placebo) did not correlate with the likelihood of remission. [50]  

A 2013 meta-analysis states that a childhood diagnosis of SAD significantly increases the risk of panic disorder and other anxiety disorders in adulthood. The researchers found no association between SAD in childhood with major depression or substance use disorders in adulthood. [51]  The latter finding is in direct contrast to other studies that suggest an association between childhood anxiety disorders and depression and substance use disorder in adulthood. [41] [52]  However, these studies were not investigating separation anxiety exclusively.

• Complications

Childhood anxiety disorders are associated with school absenteeism and educational underachievement as young adults. Anxiety disorders also confer considerable functional impairment and economic costs due to lost caregiver productivity and treatment. [41] [52]

A recent study reported higher impairment in visuospatial working memory, semantic memory, oral language, and word writing in children with anxiety disorders. Approximately 83% of the children studied in this group had a diagnosis of SAD (after a formal diagnostic interview with a clinician), but most of the children had more than one anxiety-related disorder. Children with higher anxiety severity performed poorly in all tested fields, which included visuospatial working memory, inferential processing, word reading, writing comprehension, copied writing, and semantic verbal fluency. This study suggests memory and language deficits are present in some children with anxiety disorders, and the severity and number of anxiety diagnoses correlate with lower performance in memory and language domains. [40]

Recent studies have also suggested a link between SAD and adult personality disorders. One study found that adult patients with SAD and heightened early separation anxiety had higher rates of Cluster C personality disorder when compared to those without elevated early separation anxiety. [53]  Additionally, fear of abandonment is an overlapping symptom with borderline personality disorder. [47]

An anxiety disorder is also reported as a risk factor for suicidality, even after controlling for co-occurring mental health disorders and life stress. [54]  Estimates of population-attributable risk suggested a 7 to 10% risk of suicidality in adolescent patients with anxiety disorders. [54]

• Deterrence and Patient Education

Parent education is essential for ensuring the successful treatment of children diagnosed with SAD. Parents benefit from learning reinforcement techniques that lessen anxiety in children and deter avoidance behaviors. Some parents may also benefit from treatment for their anxiety or mental health issues contributing to their child’s psychopathology. 

Parents and caregivers should be educated regarding the expected treatment duration, the length of time before effect onset, and the potential adverse effects of psychopharmacological treatment. Finally, parents should be heavily involved in CBT and be educated regarding the principles of positive and negative reinforcement patterns so behavioral improvement can continue at home.

Although the condition cannot be prevented per se, patients can significantly benefit from early diagnosis. The United States Preventive Services Task Force recommends universal screening of children and adolescents aged 8 to 18 years for anxiety disorders using validated screening tools such as SCARED. [55]  They found insufficient evidence for or against screening for anxiety disorders in children younger than 7 years.

• Enhancing Healthcare Team Outcomes

The diagnosis and management of separation anxiety disorder require the efforts of a coordinated interprofessional healthcare team. Pediatric providers are the most likely clinicians to encounter children with SAD. Multiple studies show that patients with anxiety disorders tend to have more frequent medical visits and increased healthcare utilization rates, especially for comorbid medical conditions or somatic complaints. Children with suspected SAD should be promptly referred for a behavioral health evaluation by a child and adolescent psychiatrist.

Barriers to appropriate diagnosis and treatment of patients with SAD include time constraints, unfamiliarity with diagnosing and managing anxiety disorders, concerns of stigmatizing patients, and reluctance to speak with parents or adult patients about mental illness. To overcome these barriers, there have been increased efforts in developing collaborative care models for training pediatricians to identify and refer children with anxiety disorders to psychiatric professionals in-clinic or by telehealth. [41]  

Once the diagnosis is made, patients and family members may require intensive psychotherapy and psychoeducation to benefit from the treatment plan and understand expected outcomes. Parents need education regarding maladaptive parenting styles so they may be avoided at home. The clinical nurse plays a crucial role in educating parents and caregivers, reinforcing the techniques learned in therapy so they may be practiced at home. When pharmacotherapy is initiated, the clinical pharmacist assists in monitoring for adverse effects of the medications prescribed, performing medication reconciliation, and offering patient medication counseling. A collaborative interprofessional team of clinicians, behavioral therapists, nurses, and pharmacists can optimize clinical outcomes for separation anxiety disorder and help decrease the global burden of this disease. [Level 4]

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Disclosure: Joshua Feriante declares no relevant financial relationships with ineligible companies.

Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.

Disclosure: Bettina Bernstein declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Feriante J, Torrico TJ, Bernstein B. Separation Anxiety Disorder. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Review Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management. [CNS Drugs. 2001] Review Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management. Masi G, Mucci M, Millepiedi S. CNS Drugs. 2001; 15(2):93-104.
• Review Adult separation anxiety disorder in DSM-5. [Clin Psychol Rev. 2013] Review Adult separation anxiety disorder in DSM-5. Bögels SM, Knappe S, Clark LA. Clin Psychol Rev. 2013 Jul; 33(5):663-74. Epub 2013 Apr 2.

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Introduction to Separation Anxiety: A Guide to the Clinical Syndrome

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Seemingly newly recognized yet prevalent and ubiquitous, separation anxiety has only been officially acknowledged by the DSM as affecting adults as well as children since the publication of DSM-5 (2013). Yet its prevalence, which varies by country and culture is broad. Its importance has been well-known and well-described for decades, particularly if we broaden the strict description of the DSM syndrome a bit to encompass attachment dysregulation and its complicated psychiatric and emotional fallout. Frequently comorbid with other mood and anxiety disorders, the presence of separation anxiety disorder imparts a worse clinical course, more impairment in role functioning, and decreased efficacy of treatment, regardless of modality, regardless of primary mood or anxiety disorder diagnosis. The symptoms of separation anxiety can be overshadowed by other comorbidities, such as mood or other anxiety disorders. There is some evidence that improvements in adult separation anxiety and related attachment status may be active mechanisms of change in affect-focused psychotherapies for mood and anxiety disorders, making this a crucial mediator of treatment response to investigate across research domains.

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Silove D, Alonso J, Bromet E, et al. Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. Am J Psychiatry. 2015;172:647–56.

Article   PubMed   PubMed Central   Google Scholar  

Baldwin DS, Gordon R, Abelli M, Pini S. The separation of adult separation anxiety disorder. CNS Spectr. 2016;21(4):289–94. https://doi.org/10.1017/S1092852916000080 .

Article   PubMed   Google Scholar  

Elbay RY, Görmez A, Kılıç A, Avcı SH. Separation anxiety disorder among outpatients with major depressive disorder: prevalence and clinical correlates. Compr Psychiatry. 2021;105:152219. https://doi.org/10.1016/j.comppsych.2020.152219 . Epub 2020 Dec 19.

Milrod B, Keefe JR, Choo TH, Arnon S, Such S, Lowell A, Neria Y, Markowitz JC. Separation anxiety in PTSD: a pilot study of mechanisms in patients undergoing IPT. Depress Anxiety. 2020:1–10. https://doi.org/10.1002/da.23003 .

Milrod B, Markowitz JC, Gerber AJ, Cyranowski J, Altemus M, Shapiro T, Hofer M, Glatt C. Childhood separation anxiety and the pathogenesis and treatment of adult anxiety. Am J Psychiatr. 2014;171:34–43.

Feske U, Frank E, Mallinger AG, Houck PR, Fagiolini A, Shear MK, Grochocinski VJ, Kupfer DJ. Anxiety as a correlate of response to the acute treatment of bipolar I disorder. Am J Psychiatry. 2000;157:956–62.

Article   CAS   PubMed   Google Scholar  

Pini S, Abelli M, Shear KM, Cardini A, Lari L, Gesi C, Muti M, Calugi S, Galderisi S, Troisi A, Bertolino A, Cassano GB. Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatr Scand. 2010;122(1):40–6. https://doi.org/10.1111/j.1600-0447.2009.01480.x . Epub 2009 Oct 13.

Barber JP, Milrod B, Gallop R, Solomonov N, Rudden MG, McCarthy KS, Chambless DL. Processes of therapeutic change: results from the Cornell-Penn study of psychotherapies for panic disorder. Journal of Counseling Psychology. 2020;67(2):222–31. https://doi.org/10.1037/cou0000417 . ISSN: 0022-0167.

Markowitz JC, Milrod B, Leuyten P, Holmqvist R. Mentalizing in interpersonal therapy. Am J Psychother. 2019;72:95–100.

Milrod B. An epidemiological contribution to clinical understanding of anxiety. Am J Psychiatr. 2015;172:601–2.

White LO, Schulz CC, Schoett MJS, Kungl MT, Keil J, Borelli JL, Vrtička P. Conceptual analysis: a social neuroscience approach to interpersonal interaction in the context of disruption and disorganization of attachment (NAMDA). Front Psychiatry. 2020;11:517372. https://doi.org/10.3389/fpsyt.2020.517372 . eCollection 2020.

Finsaas MC, Klein DN. Adult separation anxiety: personality characteristics of a neglected clinical syndrome. J Abnorm Psychol. 2021;130(6):620–6. https://doi.org/10.1037/abn0000682 .

Cyranowski J, Milrod B. Separation anxiety disorder in the American Psychiatric Association’s textbook of treatments for psychiatric disorders Ed. Gabbard G, editor. Washington, DC: American Psychiatric Press, 2014.

Google Scholar  

Cassano GB, Michelini S, Shear MK, Coli E, Maser JD, Frank E. The panic-agoraphobic spectrum: a descriptive approach to the assessment and treatment of subtle symptoms. Am J Psychiatry. 1997;154(6 Suppl):27–38. https://doi.org/10.1176/ajp.154.6.27 .

Frank E, Shear MK, Rucci P, Cyranowski JM, Endicott J, Fagiolini A, Grochocinski VJ, Houck P, Kupfer DJ, Maser JD, Cassano GB. Influence of panic-agoraphobic spectrum symptoms on treatment response in patients with recurrent major depression. Am J Psychiatry. 2000;157(7):1101–7. https://doi.org/10.1176/appi.ajp.157.7.1101 .

Carmassi C, Dell’Oste V, Ceresoli D, Moscardini S, Bianchi E, Landi R, Massimetti G, Nisita C, Dell’Osso L. Frequent attenders in general medical practice in Italy: a preliminary report on clinical variables related to low functioning. Neuropsychiatr Dis Treat. 2019;15:115–25.

Preter S, Shapiro T, Milrod B. Child and adolescent anxiety psychodynamic psychotherapy: a manual. Oxford: Oxford University Press; 2018. Print ISBN-13:9780190877712.

Book   Google Scholar  

Milrod B, Shear MK. The psychodynamic treatment of panic disorder. Hosp Community Psychiatry. 1991;42:311–2.

CAS   PubMed   Google Scholar  

Busch F, Milrod B, Singer M, Aronson A. Panic focused psychodynamic psychotherapy: eXtended range: psychodynamic psychotherapy for anxiety disorders: a transdiagnostic treatment manual. Milton Park: Taylor & Francis, LLC; 2012.

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Milrod, B., Pini, S. (2023). Introduction to Separation Anxiety: A Guide to the Clinical Syndrome. In: Pini, S., Milrod, B. (eds) Separation Anxiety in Adulthood. Springer, Cham. https://doi.org/10.1007/978-3-031-37446-3_1

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Home > Graduate College > Student Work > Dissertations and Theses @ UNI > 1575

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Separation anxiety within the school context: a qualitative study of the beliefs and practices of parents and teachers.

Lauryn C. Muller , University of Northern Iowa

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Separation anxiety in adolescence; Separation anxiety in children; Academic theses;

This paper presents the results of a qualitative study. Data were collected from two sources close to a child/adolescent that was either diagnosed with SAD or was exhibiting the symptoms set forth by the DSM-IV-TR. The sources included the primary caregiver and the primary teacher during symptom presentation. Semi-structured interviews were conducted with both sources separately. Interviews focused on the following three research question areas: (a) Parent feelings, (b) parent involvement, and (c) desire for information/supports needed. These areas are described and discussed in detail and data are analyzed while comparing parents that work within the school system to parents that are not otherwise associated with the school system. Suggestions for future research generated by this study are presented.

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Department of Educational Psychology, Foundations, and Leadership Studies

Department of Educational Psychology and Foundations

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Charlotte M. Haselhuhn

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Muller, Lauryn C., "Separation Anxiety Within the School Context: A Qualitative Study of the Beliefs and Practices of Parents and Teachers" (2006). Dissertations and Theses @ UNI . 1575. https://scholarworks.uni.edu/etd/1575

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Do you or a loved one have separation anxiety symptoms? Taking a separation anxiety quiz or separation anxiety test online may be the first step to getting the help you need to live a fulfilling life with separation anxiety symptoms. Although not everyday will be easy with separation anxiety, once you can take inventory of what is going on, and give yourself the space to heal and find support, there will likely be improvements. Again, the first step may be this online separation anxiety quiz.

Separation anxiety tests, although a great step to take, are not a replacement of a diagnosis from a medical professional. After taking this online separation anxiety quiz or any other separation anxiety tests, it is important to discuss the results with your doctor or therapist. The separation anxiety test will function like a separation anxiety inventory, looking for thoughts, actions, and emotions that align with the typical signs of separation anxiety. 

Separation anxiety, and any separation anxiety symptoms, will vary from person to person. Mental illnesses are personal, thus so are the treatments. If, after this separation anxiety test, it is necessary for you to get help from a therapist or counselor, you and your counselor will work together to discuss the symptoms, causes, and treatment for your results of the separation anxiety quiz. 

What is Separation Anxiety?

Separation anxiety is a fear of being apart from a person, from multiple people, or from a pet. Separation anxiety is common in young children, usually those aged 2 years or younger, because they can’t yet process the idea that their parent will come back soon when they leave. However, the condition can also appear in adults surrounding a child, spouse, pet, or other loved one. Oftentimes, adults with separation anxiety fear that their loved one’s will get in harm’s way. Many children who have separation anxiety go on to struggle with the condition as an adult.

Separation anxiety is classified as an anxiety disorder. The development of separation anxiety may suggest an underlying mental health problem such as social anxiety, anxiety, or panic disorder. This condition may also exacerbate mental health concerns and lead to social isolation along with poor performance at work or school. The physical symptoms that may accompany separation anxiety can inhibit one’s day-to-day life.

Signs of Separation Anxiety

There are a handful of key mental, emotional, and physical signs of separation anxiety. Mental and emotional signs include:

• Extreme distress at the idea of being separated from a loved one
• Overwhelming fear of being alone
• Extreme concern that the loved one will be in danger of getting hurt when left alone
• Overwhelming need to always know the whereabouts of a loved one
• Fear of or refusal to sleep alone
• Fear of or refusal to partake in anything that would lead to separation
• Emotional outbursts

Potential physical symptoms of separation anxiety include:

• Sore throat

Symptoms of separation anxiety that are unique to children include:

• Frequent and extreme emotional outbursts
• Severe crying
• Constantly hanging onto parents
• Difficulty with or refusal to interact with other children
• Lacking performance in school
• Extreme resistance to attending school
• Disrupted sleep and/or nightmares
• Extreme fear of sleeping alone

How is Separation Anxiety Treated?

Separation anxiety is mainly treated with therapy, namely cognitive behavioral therapy. Group therapy can also be helpful for this condition. Severe cases of separation anxiety may benefit from doctor-prescribed medications for treatment.

Cognitive behavior therapy

Cognitive behavioral therapy is a method of therapy that aims to pinpoint the habits and thought patterns that are causing mental, emotional, or even physical strain. Cognitive behavioral therapy for separation anxiety may help the impacted individual adopt healthy thoughts and behaviors to reduce feelings of anxiety and the resulting symptoms.

In children with separation anxiety, cognitive behavioral therapy may benefit both the child and the parents. This therapy method can help parents learn strategies to lessen separation anxiety in their child.

Group therapy

Group therapy can be helpful in providing support to individuals with anxiety. Affected individuals may benefit greatly from learning management strategies from others with separation anxiety.

Medications

Anti-anxiety drugs may help in the management of separation anxiety. These medications mainly help to ease the severe symptoms of anxiety to improve day-to-day functioning. Unfortunately, anti-anxiety medications aren’t an effective cure for separation anxiety and are mainly successful when taken in conjunction with therapy.

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Separation anxiety: The alone and short of it

A nkita (name changed), an accomplished corporate lawyer in her 30s, admits she’s always been a worrier. After losing her father, however, she noticed a concerning change in herself. Gradually she couldn’t stand not knowing exactly where her husband was, or being away from him for long. “I dislike golf, but I accompany him to every weekend game,” she sighs. It got so bad that if she couldn’t immediately contact him at work, she would leave her office to find him, disrupting her daily routine and personal commitments. “I know I am behaving irrationally, but I cannot control myself,” she says.

This is how Adult Separation Anxiety Disorder may manifest. Separation anxiety is just what it sounds like: fear or distress over being separated from those you’re emotionally attached to. As kids, we have all yearned to stay close to our parents or primary caregivers 24/7 and cried when we had to be away from them even for a small period. But if those behaviours continue into late childhood and even adulthood, they can be classified as an anxiety disorder.

Dr Era Dutta, psychiatrist and founder of Mind Wellness India, explains, “Whilst in its truest sense we consider this a childhood diagnosis, it might spill over into adulthood for some. Especially those with a difficult childhood, trauma or attachment issues. As per the new guidelines of the Diagnostic and Statistical Manual of Mental Disorders, it can be diagnosed at any age.” Adults with separation anxiety disorder have heightened, functionally impairing fears related to separation.

She continues, “The fear can be real or imagined; certainly exaggerated. The mind stays constantly on high alert: scanning, predicting and exaggerating every neutral situation. As a result, there is a surge of adrenaline and cortisol in the body, which is perceived as stress making the body more prone to infections. Commonly resulting in feeling on edge, problems thinking clearly, experiencing dry mouth, physical aches and headaches. The disorder is considered alarming when the gravity of the situation is so large that it starts to impact the person’s performance, living and all aspects of life.”

While it’s normal to be concerned about the wellbeing of loved ones, people with this disorder experience high levels of anxiety, and sometimes even panic attacks, when loved ones are out of reach. They might be socially withdrawn, or show extreme sadness or difficulty concentrating when away from loved ones. In parents, the disorder can lead to strict, over-involved parenting. In relationships, one might be more likely to be an overbearing partner.

Decoding the possible reasons behind this Dr Ishita Mukerji, psychologist and editorial board member of the American Journal of Health Research, explains, “Traumatic experiences can leave behind scars that make it hard to trust the world to keep you safe. This hyper-vigilance can easily translate into fear of being alone, requiring loved ones as a constant fortress against danger. Intrusive thoughts about loved ones getting hurt can feel like relentless storm clouds over sunny days.

Building secure attachments as an adult can be challenging. You might crave constant closeness to avoid the sting of abandonment, making separation feel unbearable. Folks with general anxiety or depression might be more prone to worrying about every little ‘what if’ when separated. Stressful life changes—a new job, a big move, new ventures—can throw our brains into overdrive, making us cling tighter to what feels familiar. Ultimately, it’s all about the fear of being alone.”

Separation anxiety can show up even without these pre-existing conditions. It’s all about how vulnerable our nervous system is at the moment and how much support we feel we need in the world. So, while underlying issues can act like amplifiers for separation anxiety, it’s not exclusive.

A study published in the Journal of Anxiety Disorders found that individuals with high levels of separation anxiety experienced significantly lower levels of life satisfaction and enjoyment compared to those free from it. “Constantly anticipating the pain of separation can steal the joy from the present moment. It’s like walking into a beautiful garden, only focusing on the possibility of a thorn prick, never actually smelling the roses,” Dr Mukerji says.

Challenge the Thought

Reality check: Ask yourself how likely is this belief actually true? Look for evidence to the contrary. Is your loved one usually safe? Do they take precautions?

Probability game: Think of a scale from 0 per cent (not happening) to 100 per cent (guaranteed). Where would you realistically place this thought’s chance of happening?

Acceptance and positive reframing: Acknowledge that separation is inevitable in life, but it doesn’t have to negate the good times. Accept that endings are part of the journey, and focus on making the most of the moments you have.

Shift the Focus

Mindfulness and grounding exercises: When the storm brews, anchor yourself in the present. Try sensory exercises like naming five things you see, hear, smell, or touch. Deep breathing also works wonders.

Distraction therapy: Engage your mind in something else so that your brain forgets about the irrational apprehensions.

Positive affirmations: Counter the negatives with realistic reassurances. Remind yourself of your loved one’s resilience, past good experiences, and the safety measures in place.

Talk it out: Sharing your intrusive thoughts with a trusted friend, family member, or therapist can lighten the load