Overview
Separation Anxiety Disorder, a common childhood anxiety disorder, is characterized by non-normative distress associated with the anticipation of being away from an attachment figure.
Separation anxiety is a commonly occurring phenomenon among children, and is considered developmentally normative until about the age of 3 years.
However, a developmentally disproportionate and severe occurrence of separation anxiety may be pathological.
Initially, the diagnosis was limited to children and adolescents, wherein attachment figures are typically adults such as parents or caregivers.
In the DSM-5, the diagnostic criteria were modified to allow for diagnosis in adulthood, in the context of which, attachment figures may include their children, spouses, or romantic partners.
The manifestation of Separation Anxiety can cause severe psychological distress, as well as functional consequences affecting social, academic, and occupational aspects in the life of the individual.
A female predominance is observed in the prevalence of the disorder, and the occurrence is highest among children and gradually reduces among adolescents and adults. The factors associated with the occurrence of the disorder are often genetic, environmental, and concerned with parenting styles.
The first line of treatment of Separation Anxiety Disorder is psychotherapy, often in the form of Cognitive Behavioral Therapy. Combinations of psychotherapy and pharmacotherapy may be implemented in severe manifestations of the disorder. Parent or caregiver involvement is considered beneficial.
Signs and Symptoms
The signs and symptoms of Separation Anxiety Disorder include:
- Excessive distress at the thought of caregiver/person one is attached to leaving
- Irrational fear that something bad might happen to the caregiver/attachment figure
- Pervasive urge to stay in touch with caregiver/attachment figures
- Worrying about being at risk of kidnapping, getting lost, or getting in an accident which would stop them from reuniting with caregiver/attachment figure
- Being reluctant to leave the house alone
- In children, clingy or shadowing behavior
- Being unable to fall asleep alone
- Nightmares with themes that reflect on the anxiety felt
- Bedwetting
- Irritability
- Somatic symptoms including headache, nausea, breathing difficulties, vomiting, chest pain, increased heart rate, dizziness
Risk Factors
There is a sex difference in the prevalence of Separation Anxiety Disorder, with a female preponderance observed in community samples. Reportedly, among males, there is a greater chance of adult-onset Separation Anxiety Disorder.
Typically, the onset of the disorder is in childhood, with the average lying at 6-7 years.
Separation Anxiety Disorder that manifests in childhood may persist into adolescence and adulthood, as well as serve as a precursor to other anxiety disorders. The prevalence of the disorder reduces with increase in age.
Multiple correlates have been identified with relation to Separation Anxiety Disorder. Genetic components are outlined by a family history of anxiety disorders among first and second-degree relatives of individuals diagnosed with the disorder.
A strong heritability factor has also been determined through twin studies.
The interaction of genetic and environmental factors is significant in the development of Separation Anxiety Disorder. Perinatal factors, such as smoking or alcohol consumption during pregnancy, and low weight at birth have been linked to increased chances of mental health problems in children.
A genetic propensity to develop anxiety may be present among some children, and the experience of environmental influences may increase risks.
Factors such as divorce, death of a parent, military leave, foster care, alcoholism among parents, and occupational relocation may contribute.
Parenting styles can also have an impact on the development of the disorder. Caregiving by those with anxious tendencies, as well as behaviors such as co-sleeping, reinforcement of avoidance behavior in anxiety-provoking situations, and not encouraging autonomy have been considered as correlates.
High comorbidities with generalized anxiety disorder, specific phobia, and depression tend to be present among children as well as adults.
Panic disorder, posttraumatic stress disorder, social anxiety disorder, personality disorders, bipolar disorders, and obsessive-compulsive disorder may present as a comorbidity among adults. There is also a likelihood of disruptive behavior disorders co-occurring with the disorder.
Diagnosis
The diagnosis of Separation Anxiety Disorder is based on thorough clinical assessment with the help of structured interviews, diagnostic criteria, and evaluation tools.
Especially among children, it is important to make the distinction between normative separation anxiety and the presence of Separation Anxiety Disorder.
In most cases, separation anxiety is present starting from between 6-12 months, upon the formation of attachment with caregivers, peaks at age 3, and gradually dissipates after that. This can be a sign of healthy attachment.
Upon ruling out normative separation anxiety, as well as conducting tests to exclude physical causes, psychological evaluations are carried out.
The use of well-formulated screening tools, administered to parents or children, or both, is made. In cases dealing with young children whose communication and cognitive skills are still underdeveloped, the administration of self-report measures may prove to be challenging.
The SAAI (Separation Anxiety Avoidance Inventory) has been specifically created in order to help diagnose the disorder.
Additionally, SCARED (Screen for Child Anxiety Related Emotional Disorders) and SCARED-R (Screen for Child Anxiety Related Emotional Disorders-Revised), SCAS (Spence Childrenโs Anxiety Scale), SASC (Separation Anxiety Scale for Children) may be used with children.
The ASA-27 (Adult Separation Anxiety Questionnaire) examines symptoms of separation anxiety experienced after the age of 18.
The following are the DSM-5 criteria for Separation Anxiety Disorder:
- Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
- Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (e.g., headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
- The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
- The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning
- The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
It is also important to take cultural factors into account. In certain collectivist cultures, there may be a greater degree of social importance placed on interdependence among family members, which may be perceived erroneously in a context of symptomatic significance.
Further, Separation Anxiety Disorder often presents with school refusal behavior as a symptomatic consequence.
Since this behavior may commonly co-occur with other anxiety disorders, depression, and more, it is important to make a distinction between school refusal and Separation Anxiety Disorder based on context.
In cases of school refusal that is consequential of Separation Anxiety Disorder, the behavior tends to be more acute and mild.
Treatment
The management of Separation Anxiety Disorder is based on the severity of symptoms, and usually is carried out with the help of psychotherapeutic and pharmacological methods.
Cognitive Behavioral Therapy is the mainstay in the treatment of Separation Anxiety Disorder, and is thus considered the first-line of treatment. Both individual and group therapy settings have shown efficacy.
Therapeutic intervention may encompass many different types of therapy on the basis of the patientโs symptoms and response to treatment, including art-based therapy, CBT (Cognitive Behavioral Therapy) workbooks, as well as family-based treatment modes.
More severe manifestations of Separation Anxiety Disorder which do not respond to Cognitive Behavioral Therapy or other combinations of psychotherapy may require pharmacologic intervention.
Studies have proven very strong efficacy of SSRIs (Selective Serotonin Reuptake Inhibitors) combined with Cognitive Behavioral Therapy, and medication is usually prescribed for a period of 6 months.
In addition to psychotherapeutic and pharmacological interventions, parent or caregiver education and involvement is of importance.
Providing tools and resources to the parents helps them to adequately manage symptoms in their children, as well as facilitate coping by encouraging the development of useful strategies.
Parental or caregiver involvement in Cognitive Behavioral Therapy is also beneficial to treatment outcomes.
Differential Diagnosis
Generalized anxiety disorder: Separation anxiety disorder is distinguished from generalized anxiety disorder as the anxiety is regarding separation from attachment figures, and if other worries occur, they do not overpower the clinical aspect.
Panic disorder: Threats of separation may lead to extreme anxiety and even a panic attack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the possibility of being away from attachment figures and worry about other unpleasant events occurring, rather than experiencing an unexpected panic attack.
Agoraphobia: Unlike individuals with agoraphobia, those with separation anxiety disorder are not anxious about being trapped in situations with minimal chances of escape.
Conduct disorder: School avoidance is common in conduct disorder, but anxiety about separation is not responsible for school absences, and the child or adolescent usually prefers to stay away from, rather than return home.
Social anxiety disorder: School refusal may be due to social anxiety disorder. In such instances, the school avoidance is due to fear of being judged negatively by others rather than to worries about being separated from the attachment figures.
Posttraumatic stress disorder: Fear of separation from loved ones is common after traumatic events. In posttraumatic stress disorder (PTSD), the symptoms concern intrusions about, and avoidance of, memories associated with the traumatic event itself, whereas in separation anxiety disorder, the worries and avoidance concern the well-being of attachment figures and separation from them.
Illness anxiety disorder: Individuals with illness anxiety disorder worry about specific illnesses they may have, but the main concern is about the medical diagnosis itself, not about being separated from attachment figures.
Bereavement: Intense yearning or longing for the deceased, intense sorrow and emotional pain, and preoccupation with the deceased or the circumstances of the death are expected responses occurring in bereavement, whereas fear of separation from other attachment figures is central in separation anxiety disorder.
Depressive and bipolar disorders: These disorders may be associated with reluctance to leave home, but the main concern is not worry or fear of attachment figures, but rather low motivation for engaging with the outside world. However, individuals with separation anxiety disorder may become depressed while being separated or in anticipation of separation.
Oppositional defiant disorder: Children and adolescents with separation anxiety disorder may be oppositional in regards to being forced to separate from attachment figures. Oppositional defiant disorder should be considered only when there is persistent oppositional behavior unrelated to the separation from attachment figures.
Psychotic disorders: Unlike the hallucinations in psychotic disorders, the unusual perceptual experiences that occur in separation anxiety disorder are usually based on a misperception of an actual stimulus, occur only in certain situations and are reversed by the presence of an attachment figure.
Personality disorders: Dependent personality disorder and borderline personality disorder may have overlapping symptoms of separation anxiety disorder but differ regarding the cause of the disorders.
Comorbidity
In children, separation anxiety disorder is highly comorbid with generalized anxiety disorder and specific phobia. In adults, common comorbidities include specific phobia, PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia, obsessive-compulsive disorder, personality disorders, depressive and bipolar disorders.
Specialist
In childhood-onset Separation Anxiety Disorder, the onus of the diagnosis of Separation Anxiety Disorder often falls on paediatric healthcare providers, though referrals may be made to child psychiatrists or psychologists.
Skilled therapists are responsible for the implementation of Cognitive Behavioral Therapy, as they have undergone adequate training to do so. In cases of treatment-resistant Separation Anxiety Disorder, a referral needs to be made to a psychiatrist to consider differential diagnoses.
It is also important to screen for anxiety or depression among caregivers, and offer treatment support if need be.
Among adults, primary healthcare providers may make referrals to psychiatrists or clinical psychologists in order to confirm a diagnosis.
