Separation Anxiety Disorder

What is separation anxiety disorder?

Separation anxiety disorder is a mental health condition that affects children and adults. It causes a person to feel excessive fear or anxiety when separated from a close attachment figure or anticipating separation. The fear and anxiety are out of proportion to the situation and not developmentally appropriate. A child’s attachment figure is usually a parent but can be anyone they’ve bonded with, including a grandparent or other caregiver. In adults, the anxiety usually centers on their child or romantic partner.

You might be familiar with the term “separation anxiety” as something babies experience when a primary caregiver leaves their side. That’s because separation anxiety is a normal developmental stage babies go through as they learn more about the world around them. They typically grow out of this stage by age 3.

But some older kids experience separation anxiety beyond the point where it’s developmentally expected. That’s when healthcare providers consider a diagnosis of separation anxiety disorder. Symptoms can also appear in adults with or without a history of childhood separation anxiety.

Separation anxiety disorder can get in the way of daily life. Children with this condition may refuse to go to school. Adults may miss work or have trouble focusing.

But take heart in knowing it doesn’t always have to be this way. If you think you or a loved one might have separation anxiety disorder, contact a healthcare provider. They’ll talk to you about what’s happening and, if necessary, recommend treatment like therapy or medications.

What are separation anxiety disorder symptoms?

A person with separation anxiety disorder will have three or more of the following symptoms:

• Feel distress when apart from an attachment figure or anticipating separation.
• Worry something bad (like injury or death) will happen to an attachment figure.
• Worry something bad will happen to one’s own self (like getting lost or being kidnapped) that would cause separation from an attachment figure.
• Refuse to leave home or go places like school or work due to fear of separation.
• Fear being alone (including in one part of the home) without an attachment figure nearby.
• Refuse to go to sleep without an attachment figure nearby.
• Have recurring nightmares about being separated from an attachment figure (these might include disasters like fire or murder).
• Have physical symptoms like stomachaches, headaches, vomiting or nausea when apart from an attachment figure or anticipating separation. Adolescents and adults may have heart palpitations or dizziness (these are rare in younger kids).

Recognizing separation anxiety disorder in children

Separation anxiety disorder symptoms can look a little different depending on your child’s age. For example, a preschooler might not know how to put their feelings into words. They may simply get upset. An older child might tell you about their nightmares or describe their fears in detail.

If you force a separation despite your child’s protests, then your child may appear sad or uninterested in whatever setting they’re in (like school). They may have difficulty concentrating on schoolwork and not seem to care about engaging with peers. These are behaviors their teacher might observe.

If away from home for several days (for example, at camp), a child with separation anxiety disorder might get extremely homesick and feel miserable until they’re allowed to leave. It’s also possible for a child with this disorder to show anger or even aggression toward anyone they perceive as keeping them from you.

Recognizing separation anxiety disorder in adults

When you love someone, it’s hard not to worry about them. It’s simply a part of life. But the distress with separation anxiety disorder is out of proportion to the situation. It may also start to interfere with your work or relationships. For example, you might call off work to stay with your loved one or text them often to make sure they’re OK (and worry until they reply).

When you’re living with this disorder, you might not always feel your worries are out of proportion to the situation. Maybe it’s only when your child or partner gets frustrated with your checking on them that you realize your anxiety is more than typical.

What causes separation anxiety disorder?

Researchers don’t know exactly what causes separation anxiety disorder, but they believe it’s likely a combination of genetics and environment. For example, a person might be born with a genetic change (mutation) that affects how certain chemicals in their brain work.

But genetics alone might not be enough to cause a disorder. It’s likely that an environmental factor — like a big life change or an adverse childhood experience — also plays a role. Such factors may cause epigenetic changes, or changes to chemicals attached to your genes that affect how those genes work. For example, certain epigenetic changes might affect how cells in your body “read” genes that control stress response.

Risk factors

A child may have an increased risk of developing separation anxiety disorder if they:

• Experience the loss of someone close to them.
• Go through a stressful situation like their parents getting divorced.
• Switch schools or move to a new place.
• Have a history of anxiety disorders in their biological family.

Risk factors for developing separation anxiety disorder as an adult include:

• Loss of a loved one.
• Illness in a loved one.
• Big life changes, like a move, entering a romantic relationship and becoming a parent.
• Diagnosis of an anxiety disorder as a child.
• Diagnosis of other anxiety or mental health disorders as an adult.

What are the complications of separation anxiety disorder?

Separation anxiety disorder disrupts your life and makes it hard to do necessary and desired things.

Children might:

• Have trouble focusing on schoolwork, causing them to fall behind in classes.
• Have a hard time engaging with peers or joining in social activities.
• Miss opportunities to learn, gain social skills and become more independent.

Adults might:

• Have trouble focusing on work or other responsibilities.
• Encounter conflicts in their relationships, especially with attachment figures.
• Miss opportunities to travel or do other meaningful activities.

How is separation anxiety disorder diagnosed?

Healthcare providers diagnose separation anxiety disorder in adults by:

• Talking to you about your symptoms.
• Asking you to fill out a questionnaire or a set of questions focused on your symptoms and experiences. Your responses help your provider reach (or rule out) a separation anxiety diagnosis.

Diagnosing separation anxiety disorder in children involves talking to parents or caregivers, as well as the child. Your pediatrician may ask you (and your child, if they’re old enough) to fill out a questionnaire. They may also verbally ask you questions about your child’s behavior and what you’ve observed.

Providers may refer you or your family to a psychologist or psychiatrist for further support in reaching a diagnosis.

What are the criteria for diagnosis?

Healthcare providers use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR®) to diagnose separation anxiety disorder and/or other mental health conditions that may be affecting you or your child.

According to the DSM-5-TR, a diagnosis of separation anxiety may be reached if all of the following are true:

• The person has at least three of the eight possible symptoms previously listed.
• The symptoms are persistent, lasting for at least four weeks in children or six months in adults.
• The symptoms cause the person much distress or interfere with their daily functioning (like going to school or work).
• Another diagnosis isn’t responsible for these symptoms.

For years, providers only diagnosed separation anxiety disorder in adults if they had a history of the condition as a child. But the DSM-5-TR changed this by classifying the condition as an anxiety disorder, rather than a disorder usually diagnosed before age 18. Providers now recognize that it can appear for the first time in adults at any age.

Diagnosing comorbidities

Providers also use the DSM-5-TR to diagnose comorbidities, which are other conditions a person has along with a primary diagnosis (in this case, separation anxiety disorder). It’s possible to have two or more mental health conditions, and combined, their symptoms may overlap or interact in ways that are difficult to untangle.

For example, it’s common for a child with separation anxiety disorder also to have generalized anxiety disorder or a specific phobia.

Adults with separation anxiety disorder commonly have one or more of the following comorbidities:

• Agoraphobia.
• Generalized anxiety disorder.
• Obsessive-compulsive disorder (OCD).
• Panic disorder.
• Personality disorders.
• Post-traumatic stress disorder (PTSD).
• Social anxiety disorder.
• Specific phobia.
• Depression.

Identifying comorbidities allows providers to tailor treatment to a person’s unique needs. For example, treatment might involve different types of therapy or multiple medications.

Cultural differences

Some cultures value strong interdependence among family members. This might mean family members are very close and rely on each other more than in other cultures. Such interdependence isn’t the same as separation anxiety disorder. Healthcare providers take cultural differences into account when diagnosing this condition.

How do healthcare providers treat separation anxiety disorder?

The first-line treatment for separation anxiety disorder is talk therapy (psychotherapy), especially the form known as cognitive behavioral therapy (CBT). CBT helps a person understand how their thoughts affect their actions.

Other therapy options include:

• Dialectical behavioral therapy (DBT), which helps a person find a balance between accepting who they are and welcoming change.
• Family therapy, which improves relationships among family members. In this case, it also educates everyone in your family about separation anxiety disorder.

Medications

If talk therapy doesn’t help enough, you or your child may need medication. Your provider will explain the exact type of medication that’s best and how long it’ll be needed.

Medications to treat separation anxiety disorder in children

Providers sometimes use selective serotonin reuptake inhibitors (SSRIs) to treat separation anxiety disorder in children age 6 or older. Specific medications prescribed include:

• Fluoxetine (Prozac®).
• Sertraline (Zoloft®).
• Paroxetine (Paxil®, Pexeva®).

Possible adverse effects include insomnia, vomiting and changes in appetite. A more serious concern with SSRI use in children is the increased risk for suicidal ideation.

Your child’s provider will keep a close eye on your child to look for signs they might be thinking about suicide. They’ll want to see your child for regular follow-ups, as often as once a week during the first month and then every other week during the second month. They’ll also tell you what to look out for at home

Don’t hesitate to share questions or concerns with your child’s provider at any point in this process, including before your child starts taking any medication.

Medications to treat separation anxiety disorder in adults

Your provider may prescribe antidepressants like SSRIs or anti-anxiety medications like benzodiazepines.

Your provider will tell you more about the possible side effects and risks of specific medications you’re taking. For example, benzodiazepines can be habit-forming. SSRIs may increase your risk for suicidal thoughts or behavior, especially when you first start taking them. 

All medications come with risks and benefits. You and your provider can work together to find the best treatment option for you.

If you’re thinking about suicide or you’re concerned your child is thinking about suicide, call the Suicide and Crisis Lifeline at 988. Someone is available to help you 24/7.

Is separation anxiety disorder preventable?

There’s no known way to prevent separation anxiety disorder.

As a parent or caregiver, one of the best things you can do to support your child’s mental health is to keep an open dialogue with them. Let them know they can talk to you about anything that’s on their mind at any time. Also, reassure them that you’ll be there for them, and even when they can’t see you, you’re just a phone call away. You can also talk to your pediatrician about ways to ease your child’s transition into school and other activities away from home.

What is the outlook for separation anxiety disorder in children?

Children who receive treatment — especially early on — recover well. They go to school, make friends and gradually learn to be more independent. Most don’t continue to have symptoms into adulthood or have difficulty with transitions like going away to college or getting married. Some kids just need a little extra help to enjoy the independence you know is so important for them. And once they get that support, they can start to view the world as full of opportunities — even when you’re not right by their side.

But without treatment, kids with separation anxiety disorder may have difficulty in school. They may also resist situations that involve risk or change, and this can limit their opportunities for learning and growth. They also face an increased risk of developing other mental health conditions later in life, including panic disorder or agoraphobia.

What is the outlook for separation anxiety disorder in adults?

Your healthcare provider can tell you what to expect in your unique situation. Separation anxiety affects each person a little differently. Also, people respond differently to treatment. Therapy might be enough to help you manage your symptoms or you might need medications as well — either temporarily or long term.

It’s hard to predict what you might feel like a few years from now or even next month. But working closely with your provider to manage your condition gives you the best chance at feeling less anxious and more in control of your thoughts.

Follow the treatment plan your provider gives you and attend all your follow-up appointments. Your provider will want to check how your medication is working and if it’s causing any side effects.

When should I contact a healthcare provider?

Contact a healthcare provider if you or your child have symptoms of separation anxiety disorder.

If a provider prescribes medication for you or your child, let them know right away if you notice:

• New or changing side effects.
• Behavioral changes.
• Symptoms aren’t improving or are getting worse.

If you’re thinking about suicide or you’re concerned your child is thinking about suicide, call the Suicide and Crisis Lifeline at 988. Someone is available to help you 24/7.

How common is separation anxiety disorder?

Separation anxiety disorder is the most common anxiety disorder in children under age 12. It affects about 4 in 100 children in this age group.

Separation anxiety disorder affects around 1% to 2% of adults in the U.S. This might sound like a small number, but it means as many as 1 in 50 adults have this disorder. Chances are if you’re sitting in a busy restaurant, at least one or two people there are living with separation anxiety disorder.