Separation anxiety disorder is a medical condition that is characterized by significant distress when a person is away from parents, another caregiver, or home. Unlike the occasional, mild worries that children may feel at times of separation, separation anxiety disorder can dramatically affect a person's life by limiting the ability to engage in ordinary activities. Children with the disorder become extremely upset whenever they separate from their primary caregiver, whether that person is a parent, relative, nanny, or other caregiver. Unlike children who are simply shy, children with separation anxiety disorder may become severely anxious and agitated even when just anticipating being away from their home or primary caregiver.
Separation anxiety disorder affects approximately two to five percent of children. These children, who often have additional anxiety disorders, frequently have other family members with anxiety disorders. The tendency to develop separation anxiety disorder involves complex genetic and environmental factors. top
What Does Separation Anxiety Disorder Look Like in Children and Adolescents?
A certain level of separation anxiety is an expected and healthy part of normal development that occurs in all children to varying degrees between infancy and age 6. Healthy separation anxiety is typically first seen around 8-10 months of age, when an infant becomes anxious when meeting strangers (this is called stranger anxiety ). Children also may become mildly anxious around 18-24 months of age, when they are increasingly exploring their world but wanting to return to their caregiver frequently for security.
In contrast, children with separation anxiety disorder have separation worries that are excessive and much greater than their peers. These worries can overwhelm a child, even when they involve brief separations, such as leaving to go to school, going to sleep, or staying behind at home when a parent runs an errand. The child's fears may appear to be irrational, such as the fear that the parent may suddenly die or become ill. Young people with separation anxiety disorder often go to great extremes to avoid being apart from their home or caregivers. They may protest against leaving a parent's side, refuse to play with friends, or complain about physical illness at the time of separating. Frequently, a child tolerates separation from one parent more easily than separation from the other parent.
Diagnosing separation anxiety disorder can be challenging because children with separation anxiety disorder may have more than one anxiety disorder. Children with separation anxiety disorder frequently have physical complaints, which also may need to be medically evaluated. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top
At home, children with separation anxiety disorder may experience a combination of the symptoms listed below.
- Consistent and extreme worry and fear when separating from home or primary caregiver. Children also may be extremely frightened and worried when they anticipate separation and may be unwilling to be alone.
- Persistent worry and fear that something bad may happen to their parent or to themselves. They may worry about a parent becoming sick or getting hurt. They also may worry about getting lost if separated.
- Refusal to attend school often develops, due to worries about separating
- Refusal or reluctance to participate in ordinary outings or activities . The child may not want to go out to dinner, meet friends to play, or engage in after- school programs.
- Difficulty sleeping alone . Children may insist that a parent sleep with them or may insist on sleeping with the parent in the parent's bed.
- Scary dreams about being separated
- Frequent physical complaints at times of separating . Children with separation anxiety disorder often complain about stomach aches, headaches, or other physical discomforts when they know they will have to separate.
If left untreated, the condition may lead to considerable limitations in other areas of the child's life. Peer relationships, school functioning, and family functioning may suffer, or depression may develop. In some situations, if a child believes there is no way to reduce extreme anxiety, thoughts of self-harm or not wanting to be alive may develop. top
A child or adolescent with separation anxiety disorder may try to hide symptoms while at school. As a result, a child may appear to have more symptoms at home than at school. For other children, the symptoms are particularly evident at school because of the child's difficulty leaving a parent and the resulting impact on school attendance. At school, a child with separation anxiety disorder may have a combination of the symptoms listed below.
- Difficulty transitioning from home to school . Children may have great trouble separating from their parents in the morning. This may lead to late arrival times, long and tearful morning drop-offs, or tantrums at school.
- Refusal or reluctance to attend school . Anxiety associated with this disorder is powerful and may lead a child to insist on staying at home.
- Avoidance of activities with peers. Any additional time at school may be resisted.
- Low self-esteem in social situations and academic activities
- Difficulty concentrating due to persistent worry, which may affect a variety of school activities, from following directions and completing assignments to paying attention
- Other conditions, such as generalized anxiety disorder, panic disorder, phobias, or depression , which may also be present, compounding any learning challenges. Having one mental health condition does not "inoculate" the child from having other conditions as well.
- Learning disorders and cognitive problems, which are often overlooked in this population. A child's difficulties or frustrations in school should not be presumed to be due entirely to the separation anxiety disorder. If the child still has academic difficulty after symptoms are treated, an educational evaluation for learning disabilities should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability.
- Behavioral or cognitive effects from medication . If a child is receiving medication for symptoms, new mood changes or behaviors should be discussed with parents, as they can reflect medication side effects. top
At the Doctor's Office
A child's symptoms of separation anxiety disorder may be evident during an office visit when a child refuses to meet with the clinician alone. This feature alone does not indicate a child has separation anxiety disorder, since children routinely are nervous during office visits. Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child's functioning in each area to determine the underlying cause of the child's symptoms.
Clinicians may have to deal with some of the following challenges in diagnosing and treating a child or adolescent with separation anxiety disorder.
- Symptoms vary and their appearance may change as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis.
- Other conditions, particularly other anxiety disorders, may look like separation anxiety disorder . These conditions include specific phobias (anxiety triggered repeatedly by the same object or situation, such as spiders or flying), generalized anxiety disorder (extreme anxiety throughout the day regarding many matters), social phobia (anxiety triggered by social situations), and panic disorder (unpredictable panic attacks). The symptoms of mood disorders can also be similar to the symptoms of separation anxiety disorder.
- Depression is also often found in these children
- Frequent physical complaints such as stomach aches, headaches, nausea, or injury occur in children with separation anxiety disorder. The clinician must determine whether these complaints warrant further medical investigation.
- Children may have difficulty talking about the fears around separation. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge. For example, to elicit information from a child, clinicians might ask, "What do you worry about when you go to bed alone ?"
- Children may be unaware, or unwilling to admit , that their behavior may indicate symptoms of a disorder
- Families may need to be coached about what they can reasonably expect from their child. Children who suffer from separation anxiety disorder will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms. top
How is Separation Anxiety Disorder Treated?
Separation anxiety disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and treatment professionals optimizes the care and quality of life for the child with separation anxiety disorder. top
Psychological Interventions (Counseling)
Counseling can help children with separation anxiety disorder, and everyone around them, to understand that their symptoms are caused by a disorder with complex genetic and environmental origins--not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Individual psychotherapy is generally recommended as the first line of treatment for children and adolescents with separation anxiety disorder. Children with separation anxiety disorder may carry a sense of failure, as if the disorder was their fault. Individual psychotherapy can help reduce symptoms, and can help young people to become aware of and address their feelings of failure and self-blame.
- Cognitive Behavior Therapy (CBT) can teach young people new skills to reduce anxiety when separating from a trusted adult. In CBT, a child or adolescent is helped to become aware of and to describe negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting.
- School-based counseling can be effective in helping a child with separation anxiety disorder navigate the social, behavioral, and academic demands of the school setting. top
Biological Interventions (Medicines)
While psychotherapy may be sufficient to treat some children with separation anxiety disorder, other children's symptoms do not improve significantly with psychotherapy alone. These children may benefit from medications.
The U.S. Food and Drug Administration (FDA) has not approved specific medications for the treatment of separation anxiety disorder in children and adolescents. However, medications approved by the FDA for other uses and age groups are prescribed for young people with separation anxiety disorder. The FDA allows doctors to use their best judgment to prescribe medication for conditions for which the medication has not specifically been approved.
The antidepressants Celexa, Lexapro, Luvox, Paxil, Prozac (fluoxetine), and Zoloft are commonly prescribed to treat the symptoms of separation anxiety disorder. These medicines belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI's. Other types of antidepressants, such as the tricyclic antidepressant Tofranil (imipramine) have also been reported helpful in some studies.
In most cases these medicines begin to be effective in reducing symptoms after the child or adolescent has taken them for at least 2-4 weeks. Fully 12 weeks may be required in order to determine whether the medication is going to be effective for a particular individual. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.
There is no "best" medicine to treat separation anxiety disorder, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child's life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.
The following cautions should be observed when any child or adolescent is treated with antidepressants.
- Benefits and risks should be evaluated . Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov . Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving medication. Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant. Frequent follow-up (weekly for the first month) is now advocated by the FDA for children starting an antidepressant.
- Some children who have separation anxiety disorder may also have bipolar disorder. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms . While antidepressants do not "cause" bipolar disorder, they can unmask or worsen manic symptoms.
Helpful information about specific medications can be found at www.medlineplus.gov (click on "Drug Information") and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD. top
Interventions at Home
At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with separation anxiety disorder.
- Learn about the disorder and how it is experienced by the child . Parents can more easily sympathize with a child's struggles if they understand how the child feels.
- Listen to the child's feelings . Isolation can foster low self-esteem and depression in children with separation anxiety disorder. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect.
- Keep calm when a child is upset about separating . If a child sees a parent is able to remain calm, the child can model the parent's attitude.
- Gently remind the child that he or she survived the last separation . Reassurance goes a long way and may help reduce the child's anxiety.
- Anticipate transition points that can cause apprehension, such as going to school or meeting friends for play. If a child tolerates separation from one parent more easily than from the other parent, arrange school drop-off, bedtime, and other transitions to be handled where possible by the parent from whom it is easier to separate.
- Planning for enjoyable activities at school or wherever the child is going, or describing when and how the child can contact the parent, may diminish anxiety
- Firmly, consistently, and caringly set limits . ("I know you'd like Mommy to bring you to bed, and I know this is hard for you. Mommy said good night and she'll see you first thing in the morning, and you'll make breakfast together. You've got her picture beside you to remind you that she's thinking about you. Good night now.")
- Teach relaxation techniques . Relaxation techniques include deep breathing, counting to 10, or visualizing a soothing place. Teaching children or adolescents how to relax will empower them to develop mastery over symptoms and improve a sense of control over their body.
- Help a child who has been absent from school to return to school as quickly as possible . Even if a shorter school day is necessary initially, children's symptoms are more likely to decrease when they discover that they can survive the separation.
- Support the child's participation in activities . Helping the child or adolescent to get through the separation fears and to engage in activities will encourage continued participation in healthy activities.
- Praise the child's efforts to address symptoms. Young people often feel that they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised. top
Interventions at School
There are many ways that schools can help a child with separation anxiety disorder. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following:
- Schedule check-ins on arrival to reduce the child's initial anxiety and facilitate transition into school
- Accommodate late arrival due to difficulty separating
- Identify a safe place where the child may go to reduce anxiety during stressful periods. Developing guidelines for appropriate use of the safe place will help both the student and staff.
- Develop relaxation techniques to help reduce anxiety at school. The same techniques that are useful at home can often be implemented at school as well.
- Provide times for the child to convey messages to family . Brief (a minute or so) contact with family may substantially reduce anxiety and may help children recognize that their connection to their parent is intact. (In some children, this strategy may instead heighten awareness of the separation.) In preparation for possible times when the parent is not available, identify additional people for the child to contact.
- Ask the parent to send short notes for the child to read as a reward for staying in school. These can be placed in the child's lunchbox or locker, so that they can be obtained after the child has succeeded in class for an interval.
- If the child or adolescent is avoiding school , address the cause and initiate an immediate plan for him or her to return. The young person may require gradual reintroduction to school and may readjust more quickly if allowed to attend for partial days at first.
- Encourage the child to help develop interventions . Enlisting the child's ideas in the task will lead to more successful strategies and will foster the child's ability to problem-solve. However, sometimes children will try to negotiate a "date" to attempt to return to school or go to some other activity. In most cases this strategy is not successful, and it can increase conflict ("You promised you'd go today").
- Provide assistance to the child during interactions with peers . An adult's help may be very beneficial for both the child and his or her peers.
- Be aware that transitions may be difficult for the child. When a child with separation anxiety refuses to follow directions, for example, the reason may be anxiety rather than intentional oppositionality.
- Reward a child's efforts . Every good effort, or step in the desired direction, deserves to be praised.
- Please click on School-Based Interventions for a more complete list of school accommodations for children with separation anxiety disorder
Flexibility and a supportive environment are essential for a student with separation anxiety disorder to achieve success in school. School faculty and parents together may be able to develop remedies to reduce a child's challenges. top
Many online resources and books are available to help parents, clinicians, and educators learn more about children and adolescents with separation anxiety disorder. Click here for a wide selection of resources. top
Information provided above on separation anxiety disorder draws from sources including:
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition . Washington, DC: American Psychiatric Association, 1994
Bostic, JQ and Bagnell, A. "School Consultation." In Comprehensive Textbook of Psychiatry, 8th Edition . Kaplan, BJ and Sadock, VA, eds. Philadelphia: Lippincott Williams and Wilkins , 2004
Bostic JQ and Egan, H. "School Refusal." In Psychiatry for the Primary Care Physician . Munson, S and Kaye, D, eds. Chapter 18:318-333, 2002
Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition . Washington, DC: American Psychiatric Association, 1999
Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition . Philadelphia: Lippincott Williams and Wilkins, 2002
Stern, TD and Herman, JB, ed. Psychiatry Update and Board Preparation . Philadelphia: McGraw-Hill, 2000 top