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Separation Anxiety Disorder

by Josephine Elia, MD

Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Affected children desperately attempt to avoid such separations. When separation is forced, these children are distressfully preoccupied with reunification. Diagnosis is by history. Treatment is with behavioral therapy for the child and family and, for severe cases, SSRIs.

Separation anxiety is a normal emotion in children between about age 8 mo and 24 mo (see Separation anxiety); it typically resolves as children develop a sense of object permanence and realize their parents will return. In some children, separation anxiety persists beyond this time or returns later; it may be severe enough to be considered a disorder. Separation anxiety disorder commonly occurs in younger children and is rare after puberty.

Symptoms and Signs

Like social anxiety disorder, separation anxiety disorder often manifests as school (or preschool) refusal.

Dramatic scenes typically occur at the time of separation. Separation scenes are typically painful for both the child and attachment figure (usually the mother but can be either parent or a caregiver). Children often wail and plead with such desperation that the parent cannot leave, resulting in protracted scenes that are difficult to interrupt. When separated, children fixate on reunification with the attachment figure and are often worried that this person has been harmed (eg, in a car accident, by a serious illness). Children may refuse to sleep alone and may even insist on always being in the same room as the attachment figure.

Children often develop somatic complaints (eg, headache, stomachache).

The child’s demeanor is often normal when the attachment figure is present. This normal demeanor can sometimes give a false impression that the problem is minor. However, some children have persistent and excessive worry about losing the attachment figure (eg, to illness, kidnapping, or death).

Separation anxiety is often compounded by a parent’s anxiety, which exacerbates the child’s anxiety; the result is a vicious circle that can be interrupted only by sensitive and appropriate treatment of parent and child simultaneously.

Diagnosis

  • Clinical evaluation

Diagnosis is by history and by observation of separation scenes. Manifestations must be present ≥ 4 wk and cause significant distress or impair functioning (eg, children are unable to participate in age-appropriate social or scholastic activities).

Treatment

  • Behavioral therapy

  • Rarely anxiolytics

Treatment is with behavioral therapy that systematically enforces regular separations. The goodbye scenes should be kept as brief as possible, and the attachment figure should be coached to react to protestations matter-of-factly. Assisting children in forming an attachment to one of the adults in the preschool or school may be helpful.

In extreme cases, children may benefit from an anxiolytic such as an SSRI (see Table: Drugs for Long-Term Treatment of Anxiety and Related Disorders). However, separation anxiety disorder often affects children as young as 3 yr, and experience with these drugs in the very young is limited.

Successfully treated children are prone to relapses after holidays and breaks from school. Because of these relapses, parents are often advised to plan regular separations during these periods to help the child remain accustomed to being away from the parents.

* This is a professional Version *