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Separation anxiety disorder

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Separation anxiety disorder

Separation anxiety disorder
Classification and external resources
ICD-10 F93.0
ICD-9 309.21
DiseasesDB 34361
eMedicine article/916737
MeSH D001010

Separation anxiety disorder (SAD) is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment (e.g. a parent, caregiver, or siblings). In infants and small children, typically between the ages of 2 months to 3 years, separation anxiety is a natural part of the developmental process. Unlike SAD, this process indicates healthy advancements in a child’s cognitive maturation and should not be considered a developing behavioral problem.[1]

According to the American Psychology Association, separation anxiety disorder is the inappropriate and excessive display of fear and distress when faced with situations of separation from the home or from a specific attachment figure. The anxiety that is expressed is categorized as being atypical of the expected developmental level and age.[2] The severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation.[3]

SAD may cause significant negative effects within areas of social and emotional functioning, family life, and physical health of the disordered individual.[2] The duration of this problem must persist for at least four weeks and must present itself before a child is 18 years of age to be diagnosed as SAD, as specified by the DSM-IV.[4]


Anxiety disorders are the most common type of psychopathology to occur in today's youth, affecting from 5–25% of children world-wide.[2] Of these anxiety disorders, SAD accounts for a large proportion of diagnoses. SAD may account for up to 50% of the anxiety disorders as recorded in referrals for mental health treatment.[2] SAD is noted as one of the earliest-occurring of all anxiety disorders.[4] Adult separation anxiety disorder affects roughly 7% of adults.

Research suggests that 4.1% of children will experience a clinical level of separation anxiety. Of that 4.1% it is calculated that nearly a third of all cases will persist into adulthood if left untreated.[2] Research continues to explore the implications that early dispositions of SAD in childhood may serve as risk factors for the development of mental disorders throughout adolescence and adulthood.[5] It is presumed that a much higher percentage of children suffer from a small amount of separation anxiety, and are not actually diagnosed. Multiple studies have found higher rates of SAD in girls than in boys, and that paternal absence may increase the chances of SAD in girls.[6]


Separation anxiety disorder should not be confused with separation anxiety. Separation anxiety occurs as babies begin to understand their own selfhood—or understand that they are a separate person from their primary caregiver. Infants often times look for family to give them a sense of comfort and familiarity, which causes separation to become challenging.[7] At the same time, the concept of object permanence emerges—which is when children learn that something still exists when it is not seen or heard. As babies begin to understand that they can be separated from their primary caregiver, they do not understand that their caregiver will return.


Symptoms may vary in severity and how individuals exhibit them. Some common symptoms that individuals with SAD display include:

  • Significant distress, worry, and fear at the thought of or event of separation;
  • Clinging to the parent, crying, throwing tantrums, and refusing to participate in activities that require separation from the attachment figure.[2]
  • Fear of harm coming to the attachment figure or the self when separated if they are separated
  • Difficulties sleeping without the attachment figure present; persistent nightmares [8]
  • Somatic symptoms including complaints of stomachaches, nausea, or headaches, which, may or may not actually be occurring [8]
  • Avoidance, refusal, reluctance and oppositional behaviors in attempt to prevent separation from occurring [9]

Neural correlates

Preliminary evidence shows that heightened activity of the amygdala may be associated with symptoms of separation anxiety disorder. Defects in the ventrolateral and dorsomedial areas of the prefrontal cortex are also correlated to anxiety disorders in children.[10]

Contributing factors and etiology

Factors that contribute to the disorder include a combination and interaction of biological, cognitive, genetic, environmental, child temperament and behavioral factors.

Commonly noted environmental factors include parenting behavior and styles of parenting. Studies have shown a correlation between the impact of parenting styles and the onset and maintenance of separation anxiety. When a parent or caregiver consistently expresses attentive, responsive, and compassionate behavior with the child, the child will be more likely to develop a healthy or “secure” attachment to their caregiver. Although a secure child may experience a level of distress when separated from their caregiver, this expression of discomfort is considered normal and the child is easily comforted at the return of their caregiver. The consistency of reassurance and responsiveness creates an environment that allows the child to feel comfortable with their surroundings. It also promotes a child’s better understand that, when separated, their caregiver will return, thus, decreasing the severity of distress in foreign situations. [11]

When parenting styles and/or behavior are inconsistent or neglectful, the emotional needs of the child are not being met, which increase the chances of a child developing an “insecure” attachment to their caregiver. Insecure relationships develop when a caregiver fails to respond to, and comfort, a child’s distress, or anxiety. The inconsistency in a parents availability and responsiveness to a child prevents the teachings of appropriate coping mechanisms and comfort that is needed in order for a child to overcome this stage (separation anxiety) of their developmental process.

Examples of parenting behavior as contributing factors may include:

  1. Low parental warmth, discouraging autonomy in child
  2. Attachment relationships with parents or caregiver — insecure or anxious attachment styles have been shown to produce feelings of vulnerability, fear of being alone, and chronic anxiety
  3. Locus of control — this phenomena revolves around a child's thoughts and ability to control one's own environment
  4. Overprotective or intrusive parenting behaviors — this parenting style may discourage a child's independence and further enforce parental dependence [2]
  5. Genetics - studies have shown that infants of mothers with an anxiety disorder had a higher risk of developing any anxiety disorder, compared with infants of mothers with no anxiety disorder.[12]

A child's temperament can also impact the development of SAD. Timid and shy behaviors may be referred to as "behaviorally inhibited temperaments" in which the child may experience anxiety when they are not familiar with a particular location or person.[8]

In the academic setting

As with other anxiety disorders, children with SAD face more obstacles at school than those without anxiety disorders. Adjustment and relating school functioning have been found to be much more difficult for anxious children.[13] In some severe forms of SAD, children may act disruptively in class or may refuse to attend school altogether. It is estimated that nearly 75% of children with SAD exhibit some form of school refusal behavior.[2]

This is a serious problem because, as children fall further behind in coursework, it becomes increasingly difficult for them to return to school.[14]

Short-term problems resulting from academic refusal include poor academic performance or decline in performance, alienation from peers, and conflict within the family.[2]

Although school refusal behavior is common among children with SAD, it is important to note that school refusal behavior is sometimes linked to generalized anxiety disorder or possibly a mood disorder.[15]

Criteria for diagnosis

Separation anxiety occurs in many infants and young children as they are becoming acclimated with their surroundings. This anxiety is viewed as a normal developmental phase between the months of early infancy until age two.[2] Other sources note that a definite diagnosis of SAD should not be presented until after the age of three.[8] Separation anxiety may be diagnosed as a disorder if the child's anxiety related to separation from the home or attachment figure is deemed excessive; if the level of anxiety surpasses that of the acceptable caliber for the child's developmental level and age; and if the anxiety negatively impacts the child's everyday life.[2]

A very important part of diagnosing SAD involves fully understanding the symptoms as the child exhibits them. A clinician must note how behaviors are displayed, the duration that they have persisted, the context in which they occur, and the severity of the symptoms.[8] It is also important to understand the possible contributing factors.

Assessment methods and tools

Assessment methods include diagnostic interviews, self-report measures from both the parent and child, observation of parent-child interaction, and specialized assessment for preschool-aged children. Various facets of a child's development including social life, feeding and sleep schedules, medical issues, traumatic events experienced, family history of mental or anxiety health issues are explored. The compilation of aspects of a child's life aids in capturing a multi-dimensional view of the child's life.[8]

Additionally, while much research has been done in efforts to further understand separation anxiety in regards to the relationship between infants’ and their caregivers, it was behavioral psychologist, Mary Ainsworth, who devised a behavioral evaluation method, [16]

Image from The Strange Situation Study originally introduced by Behavioral Psychologist, Mary Ainsworth

The Strange Situation Study

Diagnostic interviews

Clinicians may utilize interviews as an assessment tool to gauge the symptomatic occurrences to aid in diagnosing SAD. Interviews may be conducted with the child and also with the attachment figure. Interviewing both child and parent separately allows for the clinician to compile different points of view and information.[2]

Commonly used interviews include:[2]

  • Anxiety Disorders Interview Schedule for the DSM-IV, Child Parent Versions (ADIS-IV-C/P)
  • Diagnostic Interview Schedule for Children, Version IV (DISC-IV)
  • Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and lifetime version IV (K-SADS-IV)

Self-report measures

This form of assessment should not be the sole basis of a SAD diagnosis. It is also important to verify that the child who is reporting on their experiences has the cognitive and communication skills appropriate to accurately comprehend and respond to these measurements.[2] An example of a self-report tool that has been tested is: The Separation Anxiety Assessment Scale for Children (SAAS-C). The scale contains 34 items and is divided into six dimensions. The dimensions in order are: Abandonment, Fear of Being Alone, Fear of Physical Illness, Worry about Calamitous Events, Frequency of Calamitous Events, and Safety Signal Index. The first five dimensions have a total of five items while the last one contains nine items. The scale goes beyond assessing symptoms; it focuses on individual cases and treatment planning.[17]


As noted by Altman, McGoey & Sommer, it is important to observe the child, "in multiple contexts, on numerous occasions, and in their everyday environments (home, daycare, preschool)".[8] It is beneficial to view parent and child interactions and behaviors that may contribute to SAD.[2]

Dyadic Parent-Child Interaction Coding System and recently the Dyadic Parent-Child Interaction Coding System II (DPICS II) are methods used when observing parents and children interactions.[18]

Separation Anxiety Daily Diaries (SADD) have also been used to “assess anxious behaviors along with their antecedents and consequences and may be particularly suited to SAD given its specific focus on parent–child separation” (Silverman & Ollendick, 2005). The diaries are carefully evaluated for validity.[19]

Assessment of preschool-aged children

At the preschool-aged stage, early identification and intervention is crucial.[2] The communication abilities of young children are taken into consideration when creating age-appropriate assessments.[8]

A commonly used assessment tool for preschool-aged children (ages 2–5) is the Preschool Age Psychiatric Assessment (PAPA).[2] Additional questionnaires and rating scales that are used to assess the younger population include the Achenbach Scales, the Fear Survey Schedule for Infants and Preschoolers, and The Infant–Preschool Scale for Inhibited Behaviors.[8]

Preschool children are also interviewed. Two interviews that are sometimes conducted are Attachment Doll-Play and Emotional Knowledge. In both of the assessments the interviewer depicts a scenario where separation and reunion occur; the child is then told to point at one of the four facial expressions presented. These facial expressions show emotions such as anger or sadness. The results are then analyzed.[20]

Behavioral observations are also utilized when assessing the younger population. Observations enable the clinician to view some of the behaviors and emotions in specific contexts.[8]



Non-pharmacological treatments are methods of treatment that do not involve drugs. Non-pharmacological treatments are to be used before using pharmacological treatments.[2] Counseling tends to be the best replacement for drug treatments. The types of counseling typically 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 child.[21]

Behavioral therapy

Behavioral therapies are types of non-pharmacological treatment which are mainly exposure-based techniques. These include techniques such as systematic desensitization, emotive imagery, participant modelling and contingency management. Children are forced to go to school and eventually show decreasing symptoms of SAD.[3]

Contingency management

Contingency management is a form of treatment found to be effective for younger children with SAD. Contingency management revolves around a reward system with verbal or tangible reinforcement. When children undergoing contingency management show signs of independence, they are praised or given a reward. Children in preschool who show symptoms of SAD do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of SAD.[3]

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy focuses on helping children with SAD reduce feelings of anxiety through practices of exposure to anxiety-inducing situations and active metacognition to reduce anxious thoughts.[2]

According to Kendall and colleagues, there are four components which must be taught to a child undergoing CBT:[22]

  1. Recognizing anxious feelings and behaviors
  2. Discussing situations that provoke anxious behaviors
  3. Developing a coping plan with appropriate reactions to situations
  4. Evaluating effectiveness of the coping plan

The method behind CBT is that faulty cognition is the reason for the anxiety of SAD.[22]

A 1998 study of CBT on children nine and younger found 64% of the treated children did not meet the DSM's criteria for SAD. Only 5% of the waitlisted children in the study showed these results.[22]

Another study investigated the content of thoughts in anxious children who suffered from separation anxiety as well as from social phobia and/or generalized anxiety. The results added to knowledge of cognitive behavioral therapy. It is suggested that cognitive therapy for children suffering from separation anxiety (along with social phobia and generalized anxiety) should be aimed at identifying negative cognitions of one's own behavior in the threat of anxiety-evoking situations and to modify these thoughts to promote self-esteem and ability to properly cope with the given situation.[9]

Cognitive procedures are a form of treatment found to be ideal for older children with SAD.[3] The theory behind this technique is that the child's dysfunctional thoughts, attitudes, and beliefs are what lead to anxiety and cause anxious behavior.[3] Children who are being treated with cognitive procedures are taught to ask themselves if there is "evidence" to support their anxious thoughts and behaviors.[3] They are taught "coping thoughts" to use during anxiety-inducing situations and to praise themselves for handling the situation bravely.[3]


The use of pharmacological treatment, also known as pharmacotherapy, is applied in extreme cases of SAD when other treatment options have been utilized and failed.[3][22] However, it has been difficult to prove the benefits of drug treatment in patients with SAD because there have been many mixed results.[2] Despite all the studies and testings, there has yet to be a specific medication for SAD. Medication prescribed for adults from the Food and Drug Administration (FDA) are often used and have been reported to show positive results for children and adolescents with SAD.[23]

Tricyclic Antidepressants
There are mixed results regarding the benefits of using tricyclic antidepressants (TCAs), which includes imipramine and clonipramine.[24] One study suggested that imipramine is helpful for children with “school phobia,” who also had an underlying diagnosis of SAD. However, other studies have also shown that imipramine and clonipramine had the same effect of children who were treated with the medication and placebo.[25]

There are very few studies that have been published regarding the effects of benzodiazepines on patients with SAD. However, of the studies done it has been suggested that it has little to no significant benefits compared with placebo treatments.[26]

Selective serotonin reuptake inhibitors
The most promising pharmacotherapy is the use of selective serotonin reuptake inhibitors (SSRI) in adults and children.[27] Several studies have shown that patients treated with fluvoxamine were significantly better than those treated with placebo.[2] They showed decreasing anxiety symptoms with short-term and long-term use of the medication.[2]


Discomfort from separations in children from ages 8 to 14 months is normal. Children often times get nervous or afraid of unfamiliar people and places but if the behavior still occurs after the age of 6 and if it lasts longer than four weeks, the child might have Separation Anxiety Disorder. [28] About 4% of children have the disorder. Separation Anxiety Disorder is very treatable especially when caught early on with pharmacological and behavioral therapies. [29] Helping children with separation anxiety to identify the circumstances that elicit their anxiety (upcoming separation events) is important. A child's ability to tolerate separations should gradually increase over time when he or she is gradually exposed to the feared events. Encouraging a child with separation anxiety disorder to feel competent and empowered, as well as to discuss feelings associated with anxiety-provoking events promotes recovery.

Children with separation anxiety disorder often respond negatively to perceived anxiety in their caretakers, in that parents and caregivers who also have anxiety disorders may unwittingly confirm a child's unrealistic fears that something terrible may happen if they are separated from each other. Thus, it is critical that parents and caretakers become aware of their own feelings and communicate a sense of safety and confidence about separation.[30]

Longitudinal effects

Several studies aim to understand the long-term mental health consequences of SAD.[5] SAD contributed to vulnerability and acted as a strong risk factor for developing mental disorders in people aged 19–30. Specifically disorders including panic disorder and depressive disorders were more likely to occur.[5] Other sources also support the increased likelihood of displaying either of the two psychopathologies with previous history of childhood SAD.[4]

See also


  1. ^ Davidson, Tish. "Separation Anxiety." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved October 06, 2014 from
  2. ^ a b c d e f g h i j k l m n o p q r s t u v Ehrenreich, J. T; Santucci, L. C.; Weinrer, C. L. (2008). "Separation anxiety disorder in youth: Phenomenology, assessment, and treatment".  
  3. ^ a b c d e f g h Masi, G.; Mucci, M.; Millepiedi, S. (2001). "Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management.". CNS Drugs 15 (2): 93–104.  
  4. ^ a b c Beesdo, Katja; Knappe, Susanne; Pine, Daniel S. (September 2009). "Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V". Psychiatric Clinics of North America 32 (3): 483–524.  
  5. ^ a b c Lewinsohn, P. M.; Holm-Denoma, J. M.; Small, J. W.; Seely, J. R (2008). "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): 548–555.  
  6. ^ Cohen, P., Cohen, J., Kasen, S., Velez, C. N., Hartmark, C., Johnson, J., Rojas, M., Brook, J. and Streuning, E. L. (1993), An Epidemiological Study of Disorders in Late Childhood and Adolescence—I. Age- and Gender-Specific Prevalence. Journal of Child Psychology and Psychiatry, 34: 851–867. doi: 10.1111/j.1469-7610.1993.tb01094.x
  7. ^ Feigelman S. The first year. In: Kliegman RM, Stanton BF, St. Geme JW III, et al., eds. Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 8
  8. ^ a b c d e f g h i j Altman, C; McGoey, K. E.; Sommer, J. L (2009). "Anxiety in early childhood: what do we know?". Journal of early childhood and infant psychology. 
  9. ^ a b Bogels, S. M.; Zigterman, D. (2000). "Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder". Journal of abnormal child psychology 28 (2): 205–211. 
  10. ^ Blackford, Jennifer U.; Daniel S. Pine (November 2012). "Neural Substrates of Childhood Anxiety Disorders A Review of Neuroimaging Findings". Child & Adolescent Psychiatric Clinics of North America 21 (3): 501–525.  
  11. ^ Jurbergs, Nichole & Ledley, Deborah Roth (2005). Separation Anxiety Disorder. Pediatric Annals, 34(2), 728-731.
  12. ^ Andrea Schreier, Hans-Ulrich Wittchen, Michael Höfler, and Roselind Lieb. "Anxiety Disorders in Mothers and Their Children: Prospective Longitudinal Community Study." The British Journal of Psychiatry (2008). Web. 23 September 2014
  13. ^ Mychailyszyn, Matthew P.; Mendez, Julia L.; Kendall, Philip C. (2010). "School Functioning in Youth with and without Anxiety Disorders: Comparisons by Diagnosis and Comorbidity". School Psychology Review 39 (1): 106–121.  
  14. ^ Doobay, Alissa F. (April 2008). "School Refusal Behavior Associated with Separation Anxiety Disorder: A Cognitive-Behavioral Approach to Treatment". Psychology in the Schools 45 (4): 261–272.  
  15. ^ Eisen, A., Sussman, J., Schmidt, T., Mason, L., Hausler, L., & Hasim, R. (2012). Separation Anxiety Disorder. In Handbook of Child and Adolescent Anxiety Disorders (2011 ed.). Springer.
  16. ^ Mary Ainsworth | Attachment Styles | Simply Psychology. (n.d.). Retrieved November 27, 2014, from
  17. ^ Chessa, D., di Riso, D., Delvecchio, E., & Lis, A. (2012). Assessing separation anxiety in Italian youth: Preliminary psychometric properties of the Separation Anxiety Assessment Scale. Perceptual And Motor Skills, 115(3), 811-832. doi:10.2466/03.10.15.PMS.115.6.811-832
  18. ^ Thornberry Jr., T., & Brestan-Knight, E. (2011). Analyzing the Utility of Dyadic Parent-Child Interaction Coding System (DPICS) Warm-Up Segments. Journal Of Psychopathology & Behavioral Assessment, 33(2), 187-195. doi:10.1007/s10862-011-9229-6
  19. ^ Allen, J. L., Blatter-Meunier, J., Ursprung, A., & Schneider, S. (2010). Maternal daily diary report in the assessment of childhood separation anxiety. Journal Of Clinical Child And Adolescent Psychology, 39(2), 252-259. doi:10.1080/15374410903532619
  20. ^ Bettmann, J., & Lundahl, B. (2007). Tell Me a Story: A Review of Narrative Assessments for Preschoolers. Child & Adolescent Social Work Journal, 24(5), 455-475. doi:10.1007/s10560-007-0095-8
  21. ^ Medicinenet
  22. ^ a b c d Barrett, Paula M.; Ollendick, Thomas H., eds. (2003). Handbook of Interventions that Work with Children and Adolescents: Prevention and Treatment. Wiley.  
  23. ^ Suveg, Cynthia; Aschenbrand, Sasha G.; Kendall, Philip C. "Separation Anxiety Disorder, Panic Disorder, and School Refusal". Child and Adolescent Psychiatric Clinics of North America 14 (4): 773–795.  
  24. ^ Waslick, Bruce. "Psychopharmacology Interventions for Pediatric Anxiety Disorders: A Research Update". Child and Adolescent Psychiatric Clinics of North America 15 (1): 51–71.  
  25. ^ Waslick, Bruce. "Psychopharmacology Interventions for Pediatric Anxiety Disorders: A Research Update". Child and Adolescent Psychiatric Clinics of North America 15 (1): 51–71.  
  26. ^ Waslick, Bruce. "Psychopharmacology Interventions for Pediatric Anxiety Disorders: A Research Update". Child and Adolescent Psychiatric Clinics of North America 15 (1): 51–71.  
  27. ^ Suveg, Cynthia; Aschenbrand, Sasha G.; Kendall, Philip C. "Separation Anxiety Disorder, Panic Disorder, and School Refusal". Child and Adolescent Psychiatric Clinics of North America 14 (4): 773–795.  
  28. ^ Brennan, D. (Ed.). (n.d.). Separation Anxiety Disorder in Children. Retrieved from
  29. ^ Separation Anxiety Disorder. (n.d.). Retrieved from
  30. ^ Bernstein, Bettina E. Perlstein, David, ed. "Separation Anxiety". WebMD. 

External links

  • The ‘Strange Situation': Window on a Child’s Past and Future
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