Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Affected children desperately attempt to avoid such separations. When separation is forced, these children are distressfully preoccupied with reunification. Diagnosis is by clinical criteria. Treatment is with behavioral therapy for the child and family and, for severe cases, selective serotonin reuptake inhibitors (SSRIs).
(See also Overview of Anxiety Disorders in Children and Adolescents.)
Separation anxiety is a normal emotion in children between about age 8 months and 24 months; it typically resolves as children develop a sense of object permanence and realize their parents will return. 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 manifests 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 a 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 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 often develop somatic complaints (eg, headache, stomachache).
The child’s demeanor is often normal when the attachment figure is present. This normal demeanor can sometimes give a false impression that the problem is minor. However, some children have persistent and excessive worry about losing the attachment figure (eg, to illness, kidnapping, or death).
Separation anxiety 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 treatment of parent and child simultaneously.
Diagnosis of Separation Anxiety Disorder
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders (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).
Treatment of Separation Anxiety Disorder
Behavioral therapy
Rarely anxiolytics
Treatment of separation anxiety disorder is with 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, children may benefit from an anxiolytic such as a selective serotonin reuptake inhibitor (SSRI—see table Medications for Long-Term Treatment of Anxiety and Related Disorders). However, separation anxiety disorder often affects children as young as 3 years, and experience with these medications in the very young is limited.
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.
Key Points
Separation anxiety is a normal emotion in children between about age 8 months and 24 months; if it persists beyond this time 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.
A normal 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.
