Separation Anxiety Disorder in Children and Adolescents

The most significant symptom of a Separation Anxiety Disorder is excessive anxiety about being away from the home or from those to whom the person is attached (such as parents).  This anxiety is more severe than what is expected for the person's developmental level.  Fear of strangers is normal at age six months, and first exposure to new adults or new children can cause normal anxiety at first for many children or adolescents.  However, severe symptoms which persist and interfere with functioning are not normal.  For this diagnosis, symptoms must last for 4 weeks, begin before age 18, and cause significant distress or impairment in social, academic, or other important areas of functioning.

Signs and symptoms include 3 or more of the following:

  • recurrent excessive distress when separation from home or a major attachment figure occurs, or is anticipated
  • persistent and excessive worry about losing, or about possible harm befalling major attachment figures
  • persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (like getting lost or being kidnapped)
  • persistent reluctance or refusal to go to school or elsewhere because of a fear of separation
  • persistent and excessive fear or reluctance to be alone or without major attachment figures at home or without significant adults in other settings
  • persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
  • repeated nightmares involving themes of separation
  • repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

These criteria are the signs and symptoms currently designated by the American Psychiatric Association for this disorder.  They are published in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, 1994), and available in the public domain.  Diagnoses for mental health remain dominated by the medical model in this country.

Children and adolescents with this disorder may experience recurrent excessive distress about separation from home or parents.  When apart from attachment figures, they often need to know where their parents are and need to stay in touch or see them.  Some may become extremely homesick when away from home.  They may insist on returning home, and are often preoccupied with reunion fatasies.  They can be excessively worried about accidents or illnesses that could happen to attachement figures or themselves.  Children often express fear of being lost and never finding their parents again.  They can be uncomfortable about traveling independently away from the house or other familiar spots, and may avoid going places by themselves.  They may be afraid of or refuse to attend school or camp, or to visit or sleep at friends' homes, or to not go on errands alone.  These children may be unable to stay in a room by themselves.  They may demonstrate clinging behavior, staying close to and shadowing a parent.

Children with a Separation Anxiety Disorder often have trouble at bedtime, and may insist that someone stay with them until they fall asleep.  During the night, they may find their way to their parents' bed (or a sibling's bed), or may sleep outside their parents' bedroom door.  There are often nightmares which typify the child's fears, such as destruction of the family.  Physical symptoms, such as headaches, stomachaches, nausea or vomiting are common when separation occurs or is anticipated.  Heart palpitations, dizziness, and feeling faint are rare in young children, but may occur in older children.  This disorder can have an early onset, before age 6.

Children with this disorder often come from close knit families.  They can also come from families where conflict is significant, which can lead to worry about what will happen when the child is absent.  When separated they exhibit social withdrawal, sadness, difficulty concentrating on work or play, and sometimes anger or refusal to participate or respond.  Depending on age, they may have fears of animals, monsters, the dark, muggers, burglars, kidnappers, car accidents, plane travel, or other situations perceived as presenting danger to the family or themselves.  Worries about death and dying are common.  School refusal may lead to academic difficulties, school avoidance, and parental anger, frustration, or worry.  Children can complain that no one loves them or cares about them, and wish they were dead.  When extremely upset about separation happening, they may show anger or hit out at someone who is forcing separation.

When alone, children or adolescents with this disorder may report unusual experiences, such as seeing people looking into their room, scary creatures reaching for them, or feeling eyes staring at them.  Children are frequently described as demanding, intrusive, and needing constant attention.  Some children are described as unusually conscientious, compliant, and too eager to please.  They may have somatic complaints, with frequent trips to the physician or nurses office at school.  A depressed mood is frequently present and may become more persistent over time.  A Panic Disorder may develop over time.

Younger children may not express specific fears of definite threats to parents, home or themselves.  As children get older, worries or fears are often of specific dangers.  Adolescents with this disorder, especially males, may deny anxiety about separation, but it can be demonstrated in their limited independent activity and reluctance to leave home.  In older children and adolescents, it can limit the child's ability to handle changes like moving, school changes, divorce or marriage (their parents, or their own).  Adults with this disorder are typically overconcerned about their children and spouses.  It seems equally common in males as in females.

Separation Anxiety Disorder may develp after some life stress.  It may start as early as preschool, and may occur any time before age 18, although late onset in adolescents is uncommon.  Anxiety and avoidance may persist for several years.  It may be more frequent in children with mothers that have a Panic Disorder.

Counseling for this disorder can be very helpful and effective.  Usually family therapy as well as individual therapy are necessary, particularly since the child struggles with being apart from their parent for a session.  Education for parents about the disorder is an early intervention.  Developing stragegies to assist with separation for parent, child, and usually school or other setting are necessary.  These may range from behavioral and reward plans, to cognitive therapy.  Medication may be required to help the child or adolescent learn to manage the anxiety and practice handling situations.

If you think that your child or adolescent might have a Separation Anxiety Disorder, you should talk to a professional about what to do and how to get help.  If you live in southeast Massachusetts, in Plymouth county, Cranberry Counseling in Marshfield would be more than happy to answer your questions and to make an appointment to help diagnose and start a treatment plan for your child or adolescent and your family.  See the Cranberry Counseling, P.C. page, or use the Contact Us form.