Our Health Topics

Separation Anxiety Disorder

  • As a parent, it can be heartbreaking to watch your child becoming distressed and worrying about being separated from you. When this distress is excessive, ongoing and disruptive to your child’s (as well as your family’s) life, it’s likely to be separation anxiety disorder.
    Separation anxiety disorder (SAD) is an anxiety disorder that causes a child to suffer from feelings of extreme worry when they’re apart from the family members, other people or places she’s most attached to. Sometimes, just the thought of being separated causes this intense worry.

    Children with SAD may fear:

    • being lost and unable to return to home or family
    • something bad happening to a loved one during, or because of, the separation 

    While all children go through phases of “clinginess,” especially with parents, your child is likely to have separation anxiety disorder if his feelings:

    • last for at least four weeks
    • are more severe than the normal separation anxiety most children experience  

    The good news is that, like all anxiety disorders, separation anxiety disorder is very treatable in kids of all ages.

    How Boston Children's Hospital approaches separation anxiety disorder

    As one of the largest pediatric psychiatric services in New England, Children’s has a team of expert psychiatrists, psychologists and social workers ready to help you, your child and your family cope with separation anxiety disorder (SAD).

    Our Department of Psychiatry team members are leaders in researching, diagnosing and treating SAD and other anxiety disorders, as well as:

    Our approach to mental health care is evidence-based—which means that our treatments have been tested and proven effective through scientific studies, both here at our hospital and by other leading institutions worldwide. We use “talk therapy” as our primary method of treatment for anxiety, focusing on teaching children helpful thinking and coping skills to overcome symptoms and adopt new, healthier thought patterns and behaviors.

    In certain instances, we might recommend that your child begin an anti-anxiety medication regimen—always in conjunction with talk therapy. Children’s has a dedicated Psychopharmacology Clinic to help you determine whether medication might be a helpful addition to your child’s treatment plan.

    Our team is always aware that your child is, first and foremost, a child—and not merely a recipient of care. You and your family are essential members of the treatment team, and our compassionate mental health professionals will include you in the therapeutic process at every step of the way.

    Separation anxiety disorder: Reviewed by David R. DeMaso, MD
    © Children’s Hospital Boston; posted in 2011

    Boston Children's Hospital
    300 Longwood Avenue
    Boston MA 02115

     617-355-6680

     

  • What is separation anxiety disorder?
    Separation anxiety disorder (SAD) is a condition that causes a child to feel intense worry and fear at the idea or prospect of being away from family members, other people and even places (most commonly, his home) that he cares about.

    To better understand SAD, it’s helpful to understand anxiety disorders in general. People are born with the instinctive “fight or flight” response that helps us escape predators and other threats. When we’re afraid, concerned or stressed, the part of our brain responsible for the fight or flight response generates the nervous, fearful sensation we call anxiety. While everyone experiences anxiety at times, people with anxiety disorders contend with excessive worrying that doesn’t go disappear the way normal anxiety does.

    A child with an anxiety disorder can’t “just put their worries aside,” no matter how hard they try. They feel much more anxious, and for much longer periods of time, than other children do in the same situations.

    What do children with separation anxiety disorder usually worry about?
    Separation anxiety disorder is centered on the child’s fear or dread of being physically apart from loved ones (and sometimes places, such as home or school).

    Common fears experienced by children with SAD include:

    • being lost and unable to return to home or family
    • being abandoned (“If mom drops me off at school, she’ll never come back”)
    • something bad happening to a parent or other loved one during, or because of, the separation

    The consistent factor in any worry associated with separation anxiety disorder is that the child’s fear is unrealistic. What he fears will happen is very unlikely to happen. 

    While all children go through phases of “clinginess,” especially with their parents, a child is likely to have separation anxiety disorder if her feelings:

    • last for at least four weeks
    • are more severe than the normal separation anxiety phases most children experience (usually when they’re between 18 months and 3 years old)
    • disrupt her daily life and activities

    When does SAD typically emerge, and who does it affect?
    Separation anxiety disorder usually begins to emerge around the third or fourth grade (between ages 8 and 10), though it can also affect younger and older children. The disorder affects boys and girls equally. 


    Causes

    What causes separation anxiety disorder?
    Anxiety disorders like SAD are linked to biological, family and environmental factors. A chemical imbalance in the brain most likely contributes to anxiety disorders.

    Anxiety and fear can be inherited, as well as learned, from family members and others who are anxious around a child. For example, a child with a parent who is afraid of leaving home may learn to fear leaving home, too. A traumatic experience may also trigger separation anxiety (for example, the sudden death of a family member).

    Is separation anxiety disorder common?
    About 4 percent of younger children have SAD, while the estimate for adolescents is slightly lower.

    Signs and symptoms

    What are the symptoms of separation anxiety disorder?
    Symptoms vary from child to child, but are all focused on fear of being physically away from someone or something important to the child.

    Warning signs of SAD may include:

    • refusal to sleep alone
    • repeated nightmares with a theme of separation
    • excessive distress when separation from home or family occurs, or is anticipated
    • excessive worry about the safety of a family member
    • excessive worry about getting lost
    • refusing to go to school
    • fearfulness and reluctance to be alone
    • frequent stomachaches, headaches or other physical complaints with no apparent medical cause
    • muscle aches or tension
    • excessive worry about safety
    • excessive worry about sleeping away from home
    • excessive "clinginess," even when at home
    • panic attacks and/or temper tantrums at times of separation from parents or caregivers

    These symptoms are likely to signify SAD if they occur for at least a month and noticeably impact your child’s daily routine and activities.

    Questions to ask your doctor

    You and your family play an essential role in your child’s treatment for SAD. It’s important that you share your observations and ideas with your child’s treating clinician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations. 

    You’ve probably thought of many questions to ask about your child’s condition and prognosis. It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you will have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you. (If your child is old enough, you can encourage him or her to write down questions, too.)
     
    Initial questions to ask your doctor might include:

    • What criteria did you use in reaching a diagnosis of SAD?
    • Is it possible that these symptoms could point to any other condition?
    • What are the treatment goals for my child?
    • How can I encourage my child to talk and ask questions about SAD?
    • What role should I play in my child’s treatment?
    • How do I walk the fine line between reassuring my worried child and fueling the separation anxiety?
    • How should I respond if my child is in the midst of an anxious episode?
    • Will you be working with my child’s other caregivers?
    • How long do you expect my child to need therapy?
    • How can I tell if my child is making progress?
    • How should I involve my child's school in treatment?
    • How should I explain my child's condition to other members of the family?
    • Will you prescribe medication for my child? If so, what are the possible side effects?
    • How can my family and I best support my child through treatment?
    • Does anything in my child’s day-to-day routine need to change?
    • How long will it take for my child to start feeling “back to normal”?
    • What other resources can you point me to for more information? 

    FAQ

    Q: Are anxiety disorders like separation anxiety disorder common in children?
    A: Yes. Anxiety disorders, including SAD, are among the most common mental, emotional and behavioral problems affecting children. According to the U.S. Substance Abuse and Mental Health Services Administration:

    • about 13 out of every 100 children ages 9 to 17 experience some kind of anxiety disorder
    • girls are affected more often than boys
    • about half of all children diagnosed with an anxiety disorder also have a second anxiety disorder or another type of mental or behavioral disorder (such as depression

    Q: How can I tell if my child has SAD, or is just being clingy?
    A: Nearly all children experience brief periods of anxiety about being away from a parent and display clingy behavior. Typically, these normal bouts occur when a child is between 18 months and 3 years old, although older children can have passing feelings of separation anxiety at particularly stressful times.

    The difference between these normal feelings of anxiety and a disorder like SAD is that a child with separation anxiety disorder will experience an extended and extensive period of fear and distress about being apart from familiar people or places, and the degree of anxiety and fear is notably out of proportion to the reality of the situation.

    As an example, let’s say your child is starting his first day of kindergarten. He’s likely to show some anxiety and discomfort when getting up and ready for school and going into the school building for the first time. He may even cry when he returns home, and say he wants to stay with you and not have to leave again the next day.

    If this period of anxiety is minor (he is comforted by asking you questions and receiving reassurance), lasts for only a short time (for the first couple of days or so) and is replaced by a return to his normal disposition and activities soon after, this is probably normal separation anxiety.

    However, if your child remains significantly distressed about being away from you during the school day (to the point that he may feel physically ill, can’t focus on schoolwork or play and isn’t soothed by your or his teachers’ reassurance), this can be a warning sign of separation anxiety disorder.

    Q: Why is psychotherapy, or “talk therapy,” so helpful in treating SAD?
    A: Through scientific studies, we’ve learned that the brain is a “practice organ”—meaning that, whenever you feel a certain way and respond with a corresponding action, your brain quickly learns to correlate the feeling and the behavior. 

    For children with SAD, this tendency can have a decidedly negative effect. As an example, a child might feel anxious about leaving home to sleep over at a friend’s house. In response, she may insist on staying home in order to feel that she (and possibly her family) remain “safe.” The child’s brain has now made the connection between “being afraid” and “sleeping over at a friend’s house,” so that the next time the child is faced with the prospect of a sleepover, the feelings of anxiety will be as strong, if not stronger.

    Psychotherapy (“talk therapy”) is an extremely effective method of overcoming the disproportionate anxiety that is the calling card of SAD. An experienced mental health professional uses psychotherapy to help your child’s brain practice healthy responses to anxiety, replacing the damaging practices of worry and avoidance learned before. Therapy sessions teach your child:

    • how to vocalize feelings of worry and fear

    • techniques (such as deep breathing, counting to 10 or mentally picturing a relaxing place or scenario) for reducing the physical feelings associated with anxiety

    • new thought patterns to replace the destructive ones—for example, responding to an initial sense of anxiety by remembering, “There is nothing for me to be afraid of. It’s only my brain trying to trick me into feeling scared. I will be OK.” 

    Q: Why do some children need anti-anxiety medication for SAD?
    A: Some children may need the additional support of medication to ease their feelings of separation anxiety to a manageable degree, so that they can begin to benefit from psychotherapy. Here at Children’s, medication is never a standalone treatment—we only prescribe it in conjunction with talk therapy. Learn more  about how Children’s prescribes psychiatric medication. 

    Q: What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?
    A: Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

    Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

    If your child is prescribed any medication for SAD, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to address any concerns you may have. 

    Q: Can I prevent my child from developing SAD?
    A: While anxiety disorders like SAD can’t be prevented altogether, seeking treatment as soon as you notice that your child has a problem can help reduce the severity of the symptoms and improve your child’s quality of life.

    Q: What is the long-term outlook for a child with SAD?
    A: Although your child may no longer experience anxiety about being separated from loved ones or his home, it’s impossible for him to avoid feelings of anxiety in general. Since the human brain is wired for the “fight or flight” response that causes the feeling of anxiety, your child will experience periods of anxiety throughout his life, just as anyone does.

    It’s possible that he will struggle from time to time with abnormal levels of anxiety due to the pre-existing tendency toward excessive worry. However, the tools learned in psychotherapy will provide your child with coping techniques to carry into adulthood, and the majority of children with SAD have substantial improvement over the long term.

    Q: What if my child has been diagnosed with another mental health issue, in addition to separation anxiety disorder?
    A:
    A child with SAD may have another mental health condition, including:

    If your child has been diagnosed with SAD as well as another mental or behavioral health problem, the conditions must be treated at the same time. Your clinician will work to develop a treatment plan that meets your child’s specific needs. 

    Q: What is the most important thing I need to know about SAD?
    A: If you suspect your child may have SAD, it is essential to speak with a qualified mental health professional as soon as possible. Children with anxiety disorders respond well to treatment that is administered by trained clinicians. By closely working with the treatment team, you can help your child go on to enjoy an active and fulfilling life.


  • The first step in treating your child is forming an accurate and complete diagnosis. 

    How is separation anxiety disorder diagnosed at Children’s Hospital Boston?
    A child and adolescent psychiatrist, psychologist or social worker will make the diagnosis following a comprehensive mental health assessment. The assessment is conducted as an interview with you and your child.

    During the interview, you are asked to talk about your child’s symptoms, as well as his social, medical, school and family histories. Together with the mental health clinician, you arrive at an explanation of your child’s problem, which leads to a mutually agreed upon treatment plan.

  • It's entirely natural that you might be concerned right now about your child's health; a mental health problem like separation anxiety disorder can be frightening. But you can rest assured that at Boston Children's Hospital, your child is in good hands. 

    Treatments for separation anxiety disorder vary from child to child, and your clinician will work with you to determine the right approach for your child's specific symptoms and circumstances.

    Psychotherapy

    The best treatment for SAD is usually psychotherapy, or “talk therapy,” to help your child learn how to cope with her feelings of worry and fear. Coping strategies learned in therapy include:

    • identifying and talking about feelings

    • stopping automatic negative thoughts (“If I can't see my parents and know they're ok, something really awful will happen to them”)

    • relaxing the mind and body

    Anti-anxiety medications

    If your child's SAD doesn't adequately respond to psychotherapy, your clinician may add an anti-anxiety medication to the treatment plan. These medications can help your child feel more relaxed and comfortable while working on coping skills in therapy. 

    Medication is not a “standalone” treatment; we consider it part of a two-prong approach, with psychotherapy as a necessary component. Our Psychopharmacology Clinic is devoted to helping children, families and clinicians decide whether medication might be a useful part of treatment. 

    Commonly prescribed anti-anxiety medications include:

    • alprazolam (Xanax)
    • lorazepam (Ativan)
    • diazepam (Valium)
    • clonazepam (Klonopin)
    • diphenhydramine (Benadryl)
    • hydroxizine (Vistaril

    Less commonly prescribed medications that have also proven effective for SAD include:

    • buspirone (BuSpar)
    • zolpidem (Ambien

    Learn more about psychiatric medications.

    Coping and support

    The ups and downs experienced by a child—and family—living with separation anxiety disorder can feel overwhelming. In addition to the information provided here, you may find comfort and support from the following resources:

    Patient and family resources at Children's

    Children's Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the Center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.

    The Advocating Success for Kids (ASK) Program at Children's provides multidisciplinary evaluation, referral and advocacy services for children under age 14 with behavioral, emotional, learning or developmental problems, either at home or at school. ASK works with children who receive their primary care either at Boston's Bowdoin Street Community Health Center, Martha Eliot Health Center or Joseph M. Smith Community Health Center or at Children's Primary Care Center. For more information about ASK, please call 617-355-4690.

    The Experience Journal was designed by Children's psychiatrist-in-chief David DeMaso, MD and members of his team. This online collection features thoughts, reflections and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with such mental health conditions as ADHD and depression.

    Children's Integrative Therapies Team provides a number of services for hospitalized children, their families and their caregivers, including:

    • massage therapy
    • acupuncture
    • yoga
    • therapeutic touch

    Why are my friendships changing?  How can I convince my parents that being a vegetarian is heathy and right for me? What types of birth control are available to me, and how do I use them? Young men and young women may have some concerns specific to their gender, and some that they share. At Children's, the Center for Young Women's Health and Young Men's Health Site offer the latest general and gender-specific information about issues including fitness and nutrition, sexuality and health, health and development and emotional health.  

    Helpful links

    Please note that neither Boston Children's Hospital nor the Children's Department of Psychiatry unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

    Helpful links for parents

    Helpful links for teens

    Helpful links for younger children

  • At Children’s Hospital Boston, we’re dedicated to proving the effectiveness of our treatment approaches through rigorous scientific testing. Our research program is one of the largest and most active of any pediatric hospital in the world. 

    Each day, we are working toward important discoveries to propel new advances in preventing, diagnosing and treating mental and behavioral disorders. This research reinforces our ongoing commitment to enhancing mental health for all children and adolescents. 

    Our research projects with potential implications for treating SAD and other anxiety disorders include:
     

    • Michelle Bosquet, PhD, staff psychologist at Children’s, is examining how infants and children develop psychologically when their mothers are suffering from anxiety.
       
    • David Clapham, MD, PhD, chief of Children’s Basic Cardiology Research Laboratories, along with a team of collaborators, has discovered a molecular “on-off” switch for innate fear (the fear that is embedded in our genes). This breakthrough could potentially lead to more effective antianxiety drugs.
       
    • David R. DeMaso, MD, Children’s psychiatrist-in-chief, is exploring the use of new technologies to help physically ill children cope with—and communicate—their feelings of worry and stress.
       
    • Baruch Krauss, MD, attending physician in Children’s Division of Emergency Medicine, is studying new treatments—both those that involve medication, and those that do not—to help relieve acute anxiety in children who are undergoing procedures in the Emergency Room.
       
    • Jennifer LeBovidge, PhD, and her colleagues in the Children’s Division of Immunology are conducting a study of a group approach to treating children with food allergies. They aim to determine how to best help these children, and their parents, manage their allergies and cope with related feelings of anxiety. 

    Learn more about mental health research at Children’s.

    Clinical trials

    It’s possible that your child will be eligible to participate in one of Boston Children's Hospital's current clinical trials. These studies are useful for a multitude of reasons:

    Some trials are designed to evaluate the effectiveness of a particular drug, treatment or therapy on a specific disease; others help doctors to better understand how and why certain conditions occur. At any given time, we have hundreds of clinical trials underway. Of course, your motives as a parent needn’t be entirely altruistic—you’ll naturally want to know how taking part in a trial can immediately benefit your child. If your child’s physician recommends participation in one of Children’s clinical trials, that likely means that your child’s physician believes that the plan outlined in that trial represents the absolute best, latest care your child can possibly receive.

    And participation in any clinical trial is completely voluntary: We will take care to fully explain all elements of the treatment plan prior to the start of the trial, and you may remove your child from the medical study at any time.

    Find a clinical trial

    To search current and upcoming clinical trials at Children’s, go to:
    http://www.childrenshospital.org/research/clinical/Search.cfm

    To search the NIH’s list of clinical trials taking place around the world, go to:
    http://www.clinicaltrials.gov/ct2/search

Request an Appointment

If this is a medical emergency, please dial 9-1-1. This form should not be used in an emergency.

Patient Information
Date of Birth:
Contact Information
Appointment Details
Send RequestIf you do not see the specialty you are looking for, please call us at: 617-355-6000.International visitors should call International Health Services at +1-617-355-5209.
Please complete all required fields

This department is currently not accepting appointment requests online. Please call us at: 617-355-6000. International +1-617-355-6000.

This department is currently not accepting appointment requests online. Please call us at: 617-355-6000. International +1-617-355-6000.

Thank you.

Your request has been successfully submitted

You will be contacted within 1 business day.

If you have questions or would like more information, please call:

617-355-6000 +1-617-355-6000
close
Find a Doctor
Search by Clinician's Last Name or Specialty:
Select by Location:
Search by First Letter of Clinician's Last Name: *ABCDEFGHIJKLMNOPQRSTUVWXYZ
More optionsSearch
Condition & Treatments
Search for a Condition or Treatment:
Show Items Starting With: *ABCDEFGHIJKLMNOPQRSTUVWXYZ
View allSearch
Visitor Information
The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
- Sandra L. Fenwick, President and CEO
Close