Separation Anxiety Disorder

ByJosephine Elia, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Reviewed ByAlicia R. Pekarsky, MD, State University of New York Upstate Medical University, Upstate Golisano Children's Hospital

Reviewed/Revised Modified Oct 2025

v11624276

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Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure or primary caregiver. Affected children desperately attempt to avoid such separations. When separation is forced, these children are distressfully preoccupied with reunification. Diagnosis is by clinical criteria and made when symptoms have been present for ≥ 4 weeks. Treatment is with behavioral therapy for the child and family and, for severe cases, selective serotonin reuptake inhibitors (SSRIs).

Symptoms and Signs
Diagnosis
Treatment
Key Points

Separation anxiety is an expected emotion experienced by very young children between about age 8 months and 24 months; it typically resolves as children develop a sense of object permanence and realize their caregivers will return. While it lasts, separation can cause a persistent, intense fear of separation from a major caregiver. Children affected by this condition may make desperate efforts to avoid separation and experience intense anxiety around reuniting. In some children, separation anxiety persists beyond this time or returns later; it may be severe enough to be considered a disorder. Separation anxiety disorder commonly occurs in younger children and is rare after puberty.

Life stresses (eg, death of a relative, friend, or pet; a geographic move, a change in schools) may trigger separation anxiety disorder. Also, some people have a genetic predisposition to anxiety.

Symptoms and Signs of Separation Anxiety Disorder

Like social anxiety disorder, separation anxiety disorder often presents as school (or preschool) refusal.

Dramatic scenes typically occur at the time of separation. Separation scenes are typically painful for both the child and attachment figure (usually the mother but can be either parent or another caregiver). Children often wail and plead with such desperation that the parent cannot leave, resulting in protracted scenes that are difficult to interrupt. When separated, children fixate on reunification with the attachment figure and are often persistently and excessively worried that this person has been harmed (eg, in a car accident, by a serious illness). Children may refuse to sleep alone and may even insist on always being in the same room as the attachment figure.

Children can also develop somatic complaints (eg, headache, stomachache).

The child’s demeanor is often unaffected when the attachment figure is present, which can sometimes give a false impression that the problem is minor.

Separation anxiety disorder is often compounded by a parent’s anxiety, which exacerbates the child’s anxiety; the result is a vicious circle that can be interrupted only by sensitive and appropriate management of the parent and child simultaneously.

Diagnosis of Separation Anxiety Disorder

Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Diagnosis of separation anxiety disorder is by history and by observation of separation scenes. Manifestations must be present ≥ 4 weeks and cause significant distress or impair functioning (eg, children are unable to participate in age-appropriate social or scholastic activities) (1).

Diagnosis reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Washington: American Psychiatric Association, 2022.

Treatment of Separation Anxiety Disorder

Cognitive behavioral therapy
Rarely anxiolytics

Treatment of separation anxiety disorder is with cognitive behavioral therapy that systematically enforces regular separations. The goodbye scenes should be kept as brief as possible, and the attachment figure should be coached to react to protestations matter-of-factly. Assisting children in forming an attachment to one of the adults in the preschool or school may be helpful.

In extreme cases, or when cognitive behavior therapy is inadequate, children may benefit from an anxiolytic such as a selective serotonin reuptake inhibitor (SSRI). However, separation anxiety disorder often affects children as young as 3 years, and experience with these medications as well as cytochrome P450 (CYP) studies in the very young is limited (1–3).

Successfully treated children are prone to relapses after holidays and breaks from school. Because of these relapses, parents are often advised to plan regular separations during these periods to help the child remain accustomed to being away from the parents.

Treatment references

1. Zuckerman ML, Vaughan BL, Whitney J, et al. Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review. J Child Adolesc Psychopharmacol. 2007;17(2):165-174. doi:10.1089/cap.2007.0086
2. Strawn JR, Mills JA, Poweleit EA, Ramsey LB, Croarkin PE. Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents. Pharmacotherapy. 2023;43(7):675-690. doi:10.1002/phar.2767
3. Aka I, Bernal CJ, Carroll R, Maxwell-Horn A, Oshikoya KA, Van Driest SL. Clinical Pharmacogenetics of Cytochrome P450-Associated Drugs in Children. J Pers Med. 2017;7(4):14. Published 2017 Nov 2. doi:10.3390/jpm7040014

Key Points

Separation anxiety is an expected emotion experienced by children between the ages of 8 months and 24 months; if it persists beyond this age range or returns later, it may be severe enough to be considered a disorder.
Dramatic, painful scenes, with desperate wailing and pleading, typically occur at the time of separation.
An unaffected demeanor when the attachment figure is present does not mean that the problem is minor.
Treatment involves planning regular separations (including during holidays) and coaching the attachment figure to react to the child's protestations matter-of-factly.

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