Separation Anxiety Disorder

Separation anxiety disorder is characterized by developmentally excessive and impairing fear or anxiety about separation from attachment figures, typically parents. While some separation anxiety is a normal part of early development, in the disorder the distress is disproportionate, persistent, and accompanied by behaviors such as refusal to be alone or to attend school, fear that harm will befall a caregiver, nightmares about separation, and physical complaints when separation is anticipated.

Definition

A disorder defined by developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the person is attached, manifested by distress on separation, persistent worry about losing or harm coming to attachment figures, reluctance to be away from home or alone, and related physical symptoms, causing clinically significant distress or impairment.

Scope

This entry covers the clinical concept, its relationship to normative developmental separation anxiety, characteristic features, epidemiology, course, and the evidence base for treatment in young people. It is educational reference material and does not provide diagnostic thresholds or treatment instructions for individuals.

Core questions

• How is disordered separation anxiety distinguished from the normal developmental phenomenon?
• How does the presentation differ across age groups?
• What is its relationship to school refusal?
• What treatments have the strongest evidence in children and adolescents?

Key concepts

• Normative versus pathological separation anxiety
• Excessive worry about harm to attachment figures
• School refusal and reluctance to be alone
• Somatic complaints on anticipated separation
• One of the earliest-onset anxiety disorders
• Attachment and family context

Mechanisms

Separation anxiety is a normal developmental phenomenon that peaks in infancy and toddlerhood; the disorder represents a developmentally excessive and persistent form that impairs functioning. It is understood in the context of attachment, temperamental vulnerability, and family and environmental factors, and it can be precipitated or maintained by accommodating responses that allow avoidance of separation. School refusal is a common associated problem, and the disorder frequently co-occurs with other anxiety disorders.

Clinical relevance

Separation anxiety disorder can lead to school refusal, restricted activities, and family disruption, and it is associated with risk of other anxiety disorders over development. The entry describes how the condition is conceptualized and studied for reference; it is not a basis for self-diagnosis or individualized care.

Epidemiology

Separation anxiety disorder is among the most common anxiety disorders in younger children and has one of the earliest ages of onset of the anxiety disorders, with prevalence tending to decline across adolescence. Community surveys of child mental health consistently identify it as a frequent childhood anxiety diagnosis, and it shows substantial comorbidity with other anxiety disorders.

Evidence & guidelines

The AACAP practice parameter for pediatric anxiety disorders (Connolly & Bernstein, 2007) covers separation anxiety disorder, and the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008) included separation anxiety among the conditions for which cognitive behavioral therapy, sertraline, and their combination were effective. These are summarized for reference and are not treatment direction.

History

Separation distress in young children has long been described in developmental and attachment research, and separation anxiety disorder was later codified as a distinct childhood-onset diagnosis. Subsequent nosology recognized that the disorder can also occur or persist into adulthood, while epidemiologic and treatment studies established its early onset and its responsiveness to cognitive behavioral therapy.

Seminal works

• connolly-2007
• walkup-2008
• costello-2003

Frequently asked questions

Isn't separation anxiety a normal part of childhood?

Some separation anxiety is normal and peaks in infancy and toddlerhood; separation anxiety disorder is diagnosed only when the fear is developmentally excessive, persistent, and causes significant distress or impairment in everyday functioning.

How is separation anxiety disorder related to school refusal?

School refusal is a common associated problem because attending school requires separation from attachment figures, although school refusal can also arise from other anxiety and mood conditions.