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What is separation anxiety disorder?

As a parent, it can be heartbreaking to watch your child becoming distressed and worried about being separated from you. When this distress is ongoing and disruptive to your child’s (as well as your family’s) life, it is 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 apart from family members or other places and people she is attached to. Sometimes just the thought of the separation causes this intense worry.

Children with SAD may experience:

  • difficulty being away from parents or other loved ones
  • excessive worry about harm to loved ones
  • excessive worry about danger to self
  • difficulty leaving the house, even to go to school
  • difficulty sleeping
  • feeling physically ill when away from loved ones

In order to diagnose SAD, these symptoms must be present for at least four weeks and be more severe than the normal separation anxiety that most children experience.

Treatment for separation anxiety disorder usually includes therapy, medication, or a combination of both. The most common form of therapy used to treat separation anxiety disorder is called cognitive behavioral therapy (CBT). CBT involves helping children and parents to learn ways to change unhelpful thoughts and behaviors. Therapists can help parents to understand how their behavior may increase their child’s anxiety (for example, allowing their child to skip school). It is very important to seek out medical advice if you are concerned that your child has separation anxiety disorder, because if left untreated, anxieties can grow bigger.

Who is affected by separation anxiety disorder?

About 4 percent of younger children have SAD, while the estimate for adolescents is slightly lower. Girls are affected more often than boys.

How common are anxiety disorders?

Anxiety disorders are among the most common mental, emotional, and behavioral problems affecting children. About 13 out of every 100 children ages 9 to 17 years old experience some kind of anxiety disorder, such as separation anxiety disorder. Approximately 4 percent of children suffer from separation anxiety disorder.

Separation Anxiety Disorder | Symptoms & Causes

What are the symptoms of separation anxiety disorder?

Children with SAD can’t just “put their worries aside” no matter how hard they try. They feel much more anxious, and for a much longer period of time, than other children in the same situations.

Common fears experienced by children with SAD Include:

  • worry about separation
  • worry about death or harm to a loved one
  • worry about something bad happening to herself
  • worry about being alone
  • worry about sleep and nightmares

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

Physical symptoms usually occur when there is a separation or anticipated separation. They may include:

  • nausea and vomiting
  • quick breathing or difficulty catching one’s breath
  • muscle aches (especially stomach and headaches)
  • fatigue

What causes separation anxiety disorder?

Nearly all children experience brief feelings 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 during times of stress. 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 and places and the degree of anxiety or fear is notably out of proportion to the reality of the situation. Anxiety disorders like SAD are linked to biological, family and environmental factors.

  • Biological factors: The brain has special chemicals, called neurotransmitters, that send messages back and forth to control the way a person feels. Serotonin and dopamine are two important neurotransmitters that, when “out of whack,” can cause feelings of anxiety.
  • Family factors: Just as a child can inherit a parent’s hair color, a child can also inherit that parent’s anxiety. In addition, anxiety may be learned from family members and others who are noticeably stressed or anxious around a child. Parents can also contribute to their child’s anxiety without realizing it by the way they respond to their child. For example, allowing a child to miss school when they are anxious about going likely causes the child to feel more anxious the next school day.
  • Environmental factors: A traumatic experience (such as a divorce, illness, or death in the family) may also trigger the onset of separation anxiety disorder.

Separation Anxiety Disorder | Diagnosis & Treatments

How is separation anxiety disorder diagnosed?

A child may be diagnosed with separation anxiety disorder if symptoms:

  • are present for at least six months
  • cause significant distress for the child
  • do not go away, no matter how much the child tries to relax or stop worrying
  • impair functioning at home, at school, or with peers

If my child is diagnosed with an anxiety disorder, what happens next?

The clinician who evaluates your child will make recommendations for treatment. These may include: parent guidance, especially around keeping the child involved in her activities, child therapy, and, sometimes, anti-anxiety medication.

How do we treat SAD?

Treatment for separation anxiety disorders vary from child to child, and your child’s therapist will work with you to determine the best approach for your child’s symptoms and circumstances. Treatment may include parent guidance, therapy, and/or medication.

Psychotherapy, with parent and child involved, is an effective method of overcoming the disproportionate anxiety that is the calling card of SAD. An experienced mental health professional uses therapy to help your child practice healthy responses to anxiety, replacing the damaging practices of worry and avoidance learned before. Therapy sessions help you and your child:

  • how to recognize and vocalize worry and fear
  • techniques (such as breathing and imaging a relaxing scene) to reduce physical symptoms of anxiety
  • new thought patterns to replace the destructive ones; instead of a worry thought the child can remember “I will be okay. I did it before, I can do it again"
  • to approach feared situations in steps so that the child is practicing and experiencing success when separated from her parents.

There are many different medications used to help control anxiety. A prescribing clinician (psychiatrist or nurse practitioner) will choose a medication if needed that will work best to help your child.

What is the long-term outlook for a child with a separation anxiety disorder?

With proper treatment, the majority of children diagnosed with separation anxiety disorder experience a reduction or elimination of symptoms. Symptoms of SAD can recur when new developmental challenges emerge. When treatment is started early and involves the parent as well as the child, the child’s chance of recovery without multiple recurrences improves.

Separation Anxiety Disorder | FAQ

How can I tell if my child has separation anxiety disorder?

All kids experience some separation anxiety. For infants and toddlers it is a normal stage of development that's connected to developing an attachment to parents and other caregivers. In older children, certain separation fears and worries are typical for their age. For example, let’s say your child is starting his first day of kindergarten. He is likely to show some anxiety and discomfort when getting up and ready for school and going into the school for the first time. He may even cry when he comes home and say he wants to stay home and not return to school. If this period of anxiety is minor (he is comforted by reassurance), lasts only a few days, and is replaced by a return to his normal mood and activities, 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 where he is physically ill, can’t focus, isn’t soothed, and is disrupted in other activities), this may be separation anxiety disorder.

What is the difference between separation anxiety disorder in children and in adults?

Separation anxiety disorder is uncommon in adults. With anxiety in general, children usually don’t realize how intense or abnormal their feelings of anxiety have become. It can be difficult for a child to know that something is “wrong.”

How can I prevent separation anxiety disorder?

While anxiety disorders cannot be prevented altogether, seeking treatment as soon as you notice that your child has a problem can reduce the severity of the problem and improve your child’s quality of life. Some other tips include:

  • Stay calm in front of your child, as she often looks to you for how to react in new and uncertain situations.
  • Avoid providing an excessive amount of reassurance since this may signal more, not less, to worry about.
  • Teach your child how to problem solve, cope, and reassure herself.
  • Limit the avoidance of activities. Though avoidance may temporarily reduce distress, it will allow the anxiety to grow and make things more difficult for your child in the future.
  • Provide support and praise for small victories in separation rather than consequences for the difficulties, since consequences tend to increase anxiety.
Where can I go to learn more about separation anxiety disorder?

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

Separation Anxiety Disorder | Programs & Services