Separation Anxiety Disorder (SAD)
Overview
Separation Anxiety Disorder (SAD) is one of the most common childhood anxiety disorders, accounting for 50% of the referrals for anxiety-related mental health treatment in children.[1] While some degree of separation anxiety is a normal part of growing up, it becomes disordered when the anxiety presents with improper severity in an inappropriate age or context.[2]
Symptoms
In children, separation anxiety disorder is an excess of the otherwise typical anxiety associated with developing throughout one’s childhood.[3] For the separation anxiety to be considered disordered, the symptoms must last at least 4 weeks in children and adolescents, but typically occur for 6 months or more in adults.[4] Research by Feriante et al. (2023) shows that 75% of children have school refusal behaviors which can present as refusal to enter the school building once they arrive, physically clinging to parents, screaming when attempting to be separated, and vocalizing headache, stomach ache or other types of illnesses.[5] Further, separation anxiety disorder is typically presented in adults as calling, texting, or using other technological means to communicate with an attached figure upon a physical separation.[6] As a result of their actions, adults with SAD may be viewed as controlling or overprotective, however, this is how adults with SAD express their fears regarding separation.[7] While separation anxiety disorder is most common among children, Silove et al. (2015) note that 43.1% of lifetime onsets of SAD actually occur after age 18.[8]
According to the Mayo Clinic, further symptoms of separation anxiety disorder include:[9]
Recurrent and excessive distress about anticipating or being away from home or loved ones
Constant, excessive worry about losing a parent or other loved one to an illness or a disaster
Constant worry that something bad will happen, such as being lost or kidnapped, causing separation from parents or other loved ones
Refusing to be away from home because of fear of separation
Not wanting to be home alone and without a parent or other loved one in the house
Reluctance or refusing to sleep away from home without a parent or other loved one nearby
Repeated nightmares about separation
Frequent complaints of headaches, stomachaches or other symptoms when separation from a parent or other loved one is anticipated
Separation anxiety disorder may be associated with panic disorder and panic attacks (i.e., repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes.)
Causes
Currently, experts do not know how to prevent separation anxiety disorder in children and adolescents.[10] However, research by Mackintosh et al. (2006) has shown that identical twins are more likely to both have anxiety than fraternal twins, which indicates a potential genetic component in the development of anxiety.[11] Furthermore, the Mayo Clinic (2021) cites that traumatic events that may have resulted from the separation from a loved one can potentially trigger the development of SAD.[12]
Diagnosis
Separation anxiety disorder diagnosed in children usually involves adults (e.g., parents or caregivers) as their attachment figures; whereas, attachment figures for adults with SAD can be children, spouses or romantic partners.[13] Feriante et al. (2023) state that the attachment style of “anxious ambivalent” is the most common attachment style for SAD; thus inquiry into a child’s living situation and relationship with caregivers can provide perspective and clues for the attachment style the child may develop in the future.[14] Gathering these clues and information about the potential for separation anxiety disorder is important since early diagnosis can help reduce symptoms and prevent the disorder from worsening.[15]
Some screening tools for SAD include:[16]
Screen for Child Anxiety-Related Emotional Disorders: One of the most common, child and parent self-report measure, the questionnaire diagnoses between the most common pediatric anxiety disorders: generalized anxiety disorder, social phobia, SAD, somatic symptoms/panic disorder, and school phobia.
Separation Anxiety Avoidance Inventory: Specifically designed to aid in diagnosing SAD, self-avoidance questionnaire to determine the avoidance of 7 separate situations.
Child Separation Anxiety Scale: Measures worry about separation, distress about separation, opposition to separation, calm at separation.
Youth Anxiety Measure: Parent-child questionnaire developed to assess anxiety disorder symptoms in children and adolescents according to the DSM-5.
Anxiety Disorder Interview Schedule: Semi-structured diagnostic interview that primarily assesses child anxiety disorder and diagnosis is derived from parent and child interview.
Pediatric Anxiety Rating Scale: Clinician-rated scale of anxiety severity using the frequency of distress symptoms, avoidance behaviors, and interference with daily functioning.
Risk Factors
The Mayo Clinic (2021) notes the following risk factors for developing separation anxiety disorder:[17]
Life stresses or loss that result in separation (e.g., grief, illness or death of a loved one, loss of a beloved pet, divorce of parents, moving or going away to school)
Certain temperaments which are more prone to anxiety than others
Family history (e.g., including blood relatives who have problems with anxiety or an anxiety disorder)
Environmental issues (e.g., experiencing some type of disaster that involves separation)
Complications
The development of separation anxiety disorder can affect a person's quality of life throughout their lifetime. In children and teens, SAD may cause them to fall behind in coursework or have a significant absence that impairs school performance and the ability to connect with school peers.[18] In adults, separation anxiety disorder can cause significant problems in leaving home or going to work.[19] Furthermore, since severe SAD usually does not go away without treatment, it may lead to the development of panic and additional anxiety disorders in adulthood.[20]
Treatment
Separation anxiety disorder treatment depends on the severity of the symptoms. For milder symptoms, patient and parent education, support and encouragement may be sufficient.[21] On the other hand, more severe symptoms typically utilize cognitive behavioral therapy (CBT) as a first line therapy, sometimes followed by selective serotonin reuptake inhibitors (SSRIs) usually prescribed for anxiety disorders. (It is important to note there are no medications with the FAD label for SAD.)[22]
There are also multiple ways to provide support to someone with separation anxiety disorder, including:[23-25]
Encourage a child or loved one to try new experiences, experience separation and develop independence with your support
Leave your child with a trusted caregiver for short periods of time to help your child learn that he or she can count on you to return
Remind teachers that your child will need extra reassurance and support in certain situations.
Being considered someone’s attachment figure can place high demands on you - it is important to develop supportive relationships for yourself and take care of your overall health, as well.[26] If you or your child are experiencing signs of separation anxiety disorder please reach out to a licensed mental health professional for guidance and support.
Contributed by: Maria Karla Bermudez
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 Feriante J, Torrico TJ, Bernstein B. Separation Anxiety Disorder. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560793/
2 Ibid.
3 Ibid.
4 Mayo Foundation for Medical Education and Research. (2021, April 5). Separation anxiety disorder. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/separation-anxiety-disorder/diagnosis-treatment/drc-20377457
5 Feriante et al. (2023)
6 Ibid.
7 Nall, R. (2023, February 10). Separation anxiety in adults: Symptoms, treatment, and management. Medical News Today. https://www.medicalnewstoday.com/articles/322070
8 Silove D;Alonso J;Bromet E;Gruber M;Sampson N;Scott K;Andrade L;Benjet C;Caldas de Almeida JM;De Girolamo G;de Jonge P;Demyttenaere K;Fiestas F;Florescu S;Gureje O;He Y;Karam E;Lepine JP;Murphy S;Villa-Posada J;Zarkov Z;Kessler RC .(2015). “Pediatric-Onset and Adult-Onset Separation Anxiety Disorder across Countries in the World Mental Health Survey.” The American Journal of Psychiatry, pubmed.ncbi.nlm.nih.gov/26046337/. Accessed 10 May 2023.
9 Mayo Clinic (2021)
10 Separation Anxiety Disorder in Children. Stanford Medicine Children’s Health - Lucile Packard Children’s Hospital Stanford. (n.d.). http://www.stanfordchildrens.org/en/topic/default?id=separation-anxiety-disorder-90-P02582
11 Mackintosh MA, Gatz M, Wetherell JL, Pedersen NL. A twin study of lifetime Generalized Anxiety Disorder (GAD) in older adults: genetic and environmental influences shared by neuroticism and GAD. Twin Res Hum Genet. 2006 Feb;9(1):30-7
12 Mayo Clinic (2021)
13 Feriante et al. (2023)
14 Ibid.
15 Mayo Clinic (2021)
16 Feriante et al. (2023)
17 Mayo Clinic (2021)
18 Feriante et al. (2023)
19 Mayo Clinic (2021)
20 Ibid.
21 Feriante et al. (2023)
22 Ibid.
23 Mayo Clinic (2021)
24 Feriante et al. (2023)
25 Stanford Medicine Children’s Health
26 Mayo Clinic (2021)