People with Separation Anxiety Disorder experience significant fear and worry when leaving their home or losing the company of a someone to whom they are emotionally bonded, also called an “attachment figure”. In children, this appears as crying, tantrums, and clinging behavior, where the child tries to remain in close physical proximity to the parents at all times, even within the home.
Children with separation anxiety require significant devotion of time and attention from the parents, usually more so from the mother, which detracts from energy needed for the affected child’s siblings. This also causes occupational issues for the parent who needs to stay home from work when their child refuses to go to school.
These children also have delayed social development because of their reluctance to be without their parents. They often have difficulties around sleeping, including nightmares about separation and problems going to sleep by themselves. This often leads them to sleep in their parents’ bed (termed co-sleeping), which reinforces the anxious behavior. They will also avoid sleeping over at friends’ houses or going to overnight summer camp.
Adolescents with separation anxiety avoid leaving the home at socially appropriate ages and frequently do not attend college as a result. Affected adults also often live with their parents and have trouble getting jobs that require them to leave the home. If afflicted adults do manage to marry and have a family, the family becomes the focal attachment figures.
Without treatment, separation anxiety will follow a vacillating, yet chronic, course. Even with treatment, 30-40% of pediatric patients will have symptoms into adulthood. In fact, 75% of adults with anxiety disorders had Separation Anxiety Disorder as children.
Causes and Risk Factors
Separation Anxiety Disorder is the most common anxiety disorder in children, appearing in 4% of kids under 12 years old. For adolescents, the rate is 1.6%, and it is between 0.9-1.9% in adults. The average age at diagnosis is 7.5 years old, and school refusal usually begins about 3 years later.
Research with twins has revealed that 73% of the risk of developing Separation Anxiety Disorder is attributable to genetics. Research suggests that a personality trait called “behavioral inhibition to the unfamiliar” is associated with higher risks of anxiety disorders, including Separation Anxiety Disorder. Individuals with this trait display higher than normal levels of anxiety when presented with any new situations.
Extended separation from or loss of an attachment figure early in life, even right after birth, is a major risk factor for Separation Anxiety Disorder. This trauma can include separation via divorce, death, extended hospitalization, and even emotional distance. Parental, especially maternal, depression and anxiety inhibits development of attachment and emotion regulation skills in children, who are then at increased risk for anxiety disorders including separation anxiety. This anxiety results from a dysregulated fight-or-flight system, where the body reacts to non-threatening situations as if they presented a mortal danger.
Parental substance use also plays a role, with 14% of children of parents with Alcohol Use Disorder going on to develop Separation Anxiety Disorder. Pregnancy factors such as maternal tobacco and alcohol use and low birth weight also increase the risk of childhood mental health issues like separation anxiety.
Roughly two-thirds of people with Separation Anxiety Disorder have another anxiety disorder as well. The most common ones for pediatric patients are Generalized Anxiety Disorder and Specific Phobia. Most other anxiety disorders appear in adults as well as Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, Major Depressive Disorder, Bipolar Disorder, and Dependent Personality Disorder.
Diagnosing Separation Anxiety Disorder
People with Separation Anxiety Disorder experience excessive and disproportionate fear of separation from loved ones, family, or anyone with whom they are emotionally close (also called “attachment figures”).
They must have at least three of eight separation-related symptoms.
- They suffer significant grief when they are being separated or expect to be separated from their home or loved ones.
- Patients may have irrational fears that their attachment figures will get sick, be injured, or die.
- They can also fear that they themselves may get lost, be abducted, or fall ill, which would separate them from their attachment figures.
- Due to their fears, patients are wary of leaving the home, even for work, school, or vacation.
- They fear being alone at home.
- They have trouble going to sleep outside the home or anywhere not close to an attachment figure.
- Patients often have recurring nightmares surrounding the theme of separation.
- They can also experience somatic symptoms – headaches, abdominal pain, gastrointestinal upset – as part of their anxiety.
Children and teenagers must experience symptoms for at least 4 weeks to be diagnosed, while symptoms need to last 6 months for adults. Separation anxiety is normal in children until age 3-4 years old.
Fear and anxiety significantly disrupt work, school, or social lives of these people. The physical symptoms are most common in teenagers, who also frequently refuse to attend school. In fact, school refusal ultimately occurs in three quarters of children with Separation Anxiety Disorder, most commonly those in the early teen years. Anxiety about separating from parents often manifests in children aged 9-12 years, an age when kids start to spend some nights away from home occasionally (sleep overs, summer camp). Patients age 8 and under most commonly fear their caregivers will get sick or die.
Treating Separation Anxiety Disorder
Cognitive Behavioral Therapy
CBT is the first choice treatment for Separation Anxiety Disorder. In CBT, people learn to recognize the symptoms of anxiety and anxious thoughts and discover how to change and replace them. They learn relaxation techniques and then practice them in anxiety-provoking situations.
Customized CBT programs
The Coping Cat Program is a manualized, CBT-based program designed specifically for childhood anxiety disorders, including Separation Anxiety. After 16 week long treatments, children with Generalized Anxiety Disorder, Separation Anxiety Disorder, or Social Phobia have 50-66% recovery rates which are maintained on follow-up three and seven years later.
The 10 session FRIENDS program is another pediatric-focused, manualized plan that retains the core strategies of CBT but involves the parents as well. This way, the whole family can learn anxiety management skills and practice them between sessions.
CBT can also be delivered in a week long, sleep-away camp configuration. Performing CBT with a peer group provides children with separation anxiety with a good opportunity to practice their new skills in a social setting, which they are normally lacking due to the nature of their disorder.
Parent-Child Interaction Therapy is a good option for children who are too young to effectively participate in CBT (under age 7, usually). This therapy improves the parent-child relationship and teaches parents to build their child’s sense of security by increasing parental warmth. Parents are then trained how to gradually introduce their children to more anxiety-provoking situations and to reward desired behaviors.
For people who do not respond to CBT, selective serotonin reuptake inhibitors (SSRIs) are the best medication option. Both Luvox (fluvoxamine) and Prozac (fluoxetine) reduce anxiety in children with Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Phobia significantly more than placebo.
Managing Separation Anxiety Disorder
Timely treatment is crucial to ward off potential academic difficulties in school-aged patients. The goal is to get school-avoidant children to willingly return to school as quickly as possible. Children with separation anxiety in grade school have significantly more difficulties with reading and math years later in junior high school, and they are at higher risk of depression, substance use, and skipping school. Anxiety-based school refusal is associated with Separation Anxiety Disorder continuing into adulthood and with decreased chance of high school graduation.
Don’t reward the behavior
Parents should try to avoid rewarding an affected child’s behavior. When children are faced with an anxiety-provoking separation, parents reward and reinforce unwanted behavior if they are overly comforting rather than letting kids process their own emotions. For example, parents should not let a child’s reluctance to attend school sway them into repeatedly excusing the child from attending, which leads to academic and social difficulties.
Education is a crucial part of treatment because of how the stress of having a family member with separation anxiety can disrupt family dynamics. Siblings of children with separation anxiety may feel jealous of the extra attention the affected child receives. The parent to whom the child is most attached may feel exhausted, resentful of the child, and anxious, and they will benefit from learning strategies to deal with their own anxiety.
Medication side effects
Because the primary pharmacological option for treatment is SSRIs, caregivers and physicians should be on the look-out for suicidal ideation and behavior in the patient, especially in the first 8 weeks of therapy.