Separation Anxiety

Key Takeaways

• Separation anxiety disorder differs from normal separation anxiety in its intensity and ability to impair daily functioning.

• The condition can develop in adulthood but is most common in children, generally developing around the age of 7.

• Separation anxiety disorder is linked to insecure attachment styles and abandonment issues that arise during the first few years of life.

Separation Anxiety Disorder Overview

Separation anxiety disorder is the most frequently diagnosed anxiety disorder in children, affecting approximately 1% to 4% of the population, and typically developing around the age of 7. However, the prevalence of separation anxiety disorder in adults remains largely unexplored.^[1]

This is because prior to 2013, separation anxiety disorder was only clinically diagnosed in children, but since then the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has expanded the diagnosis to include adults as well.^[1]

Separation anxiety disorder is an intensified and persistent form of normal separation anxiety, which is a natural part of early development, typically manifesting between 6 to 12 months of age, and gradually diminishing from around age 3.^[2]

When a person suffers from separation anxiety disorder, even anticipating separation from a loved one, or attachment figure, can cause extreme distress. People with separation anxiety disorder have symptoms that affect their ability to cope with daily life.^[2]

In the case of an adult with separation anxiety disorder, caregivers may become overly protective of their children, or overinvolved with elderly parents. In romantic relationships, the disorder can lead to clinginess, control issues, dependency, and jealousy.^[3]

Normal Separation Anxiety versus Separation Anxiety Disorder

Separation anxiety is typically a normal part of development and does not require a professional diagnosis or treatment. It is healthy for infants and toddlers to cry and become clingy when their caregivers leave, even if it's just for a short time. This shows that the child has developed a close bond to their caregivers and desires their company.

Before the age of 3, children do not yet understand that when a person disappears, they can reappear later. This is known as object permanence and is a key developmental milestone.

The main difference between normal separation anxiety and separation anxiety disorder, is that the disorder is marked by intense fear, worry, or distress when apart from a loved one, particularly at an unusual age, or in an inappropriate context.^[2]

Additionally, if a child’s distress is constant, overwhelming, and particularly if it disrupts daily life, it is likely to be diagnosed as a disorder. For example, while a child with normal separation anxiety may be clingy or cry, children with separation anxiety disorder tend to trail behind their parents wherever they go, avoiding sleepovers, and resisting going to school.^[3][4]

Separation Anxiety Disorder Causes

While the exact cause of separation anxiety disorder is unknown, research shows that unstable caregiving styles and environmental factors may contribute to the development of the disorder. These include:^[1][2][5]

• Physically unsafe or emotionally unstable home environment

• Stressful life events (like conflict or caregiver divorce)

• Environmental changes (such as moving to a new home or school)

• Overprotective caregiving (taking over responsibilities for a child)

• Critical caregiving (expecting perfection from a child)

• Cruel caregiving (harsh discipline or threats)

• Neglectful caregiving (lack of love, affection, encouragement, guidance, or healthy discipline)

• Family accommodation of a child’s fears (such as prolonging and overcomforting a child at drop-off)

Additionally, risk factors linked to the onset of separation anxiety disorder can include:^[1][2][5]

• Modeling (copying) of caregiver anxiety

• Traumatic experiences (such as losing a loved one)

• Anxiety disorders or depression running in the family

Separation Anxiety Disorder and Abandonment Issues

Attachment theory emphasizes the importance of a child forming a bond with a caregiver early in life for healthy social, emotional, and psychological development. This psychological theory categorizes four primary attachment styles:^[2]

• Secure

• Anxious-avoidant

• Disorganized

• Anxious-ambivalent

While secure attachment is healthy, the other three attachment styles are defined as “insecure attachment.” Among individuals with separation anxiety disorder, the most common attachment style was shown to be anxious-ambivalent (insecure attachment).^[2]

A 2020 review found that insecure attachment styles were linked to anxiety disorders and subtypes of anxiety disorders (such as separation anxiety disorder). Both anxious-ambivalent attachment and separation anxiety disorder are linked to abandonment issues as they each involve fears related to loss and separation.​^[6]

While caregivers may not intentionally abandon their children, insecure attachments styles arise when a child repeatedly encounters situations where their attempts to seek closeness or emotional support are either ignored, rejected, or responded to inconsistently.^[7]

In other words, abandonment issues arise not only from physical abandonment but from emotional abandonment too. Studies have found that even infants can “sense” a caregiver’s emotional state, including their availability and responsiveness.

Developing Separation Anxiety Disorder as an Adult

In a 2022 study, adult separation anxiety disorder has been linked to a tendency to experience strong negative emotions, particularly stress and worry. The study also found that adults with separation anxiety disorder may also exhibit some level of aggression and deep emotional absorption, though to a lesser extent.^[8]

Furthermore, this modern research suggests that having a generally negative temperament (prone to stress and emotional distress) increases the likelihood of developing separation anxiety disorder as an adult. In other words, the findings reveal that having such a temperament might lead to or contribute to separation anxiety disorder rather than just appearing alongside it.^[8]

Another recent study has also found links between adult women with separation anxiety disorder and an internalization of thin-ideals. Thin-ideal internalization simply means taking society’s standard of thinness on board as a personal belief that being thin is essential for beauty, success, or self-worth. This can lead to disordered eating and negative mental health outcomes.^[9]

Separation Anxiety Disorder Symptoms and Diagnosis

According to the DSM-5, a person with separation anxiety disorder experiences excessive and developmentally inappropriate anxiety about being apart from someone they’re attached to, or their home environment. In children and adolescents, symptoms must persist for at least 4 weeks, while in adults, symptoms should last 6 months or more.^[2]

To be diagnosed, they must show at least three of the following symptoms:^[2]

• Extreme distress when anticipating or actually being separated from home or a loved one

• Constant worry about losing loved ones or something bad happening to them (illness, accidents, or death)

• Fear that something bad will happen to themselves, causing a prolonged or permanent separation

• Avoiding activities like school, work, or social events due to a fear of separation, which affects the daily ability to function

• Refusing to be left alone

• Struggling to sleep without their attachment figure nearby

• Frequent nightmares with separation themes

• Physical symptoms (like headaches or nausea) when separation happens or is expected

Diagnostic Assessments

Despite its profound effect on relationships, as well as the social and professional lives of adult sufferers, separation anxiety disorder has gone unrecognized as an anxiety disorder in adults for a long time. Even today, severe adult separation anxiety disorder is often overlooked or misdiagnosed by both researchers and healthcare professionals.^[3]

As a result, most assessments are designed to diagnose the disorder in children, and include:^[2]

• Screen for Child Anxiety-Related Emotional Disorders: A 41-item self-report instrument designed to screen for various anxiety disorders in children aged 8 to 18.

• Separation Anxiety Avoidance Inventory: A self-report and parent-report measure designed to assess the extent to which children avoid situations involving separation.

• Children’s Separation Anxiety Scale: Assesses separation anxiety symptoms in children using four key areas of focus - distress, worry, opposition, and calm.

• Youth Anxiety Measure: A self and parent-report scale developed to assess symptoms of anxiety disorders in children and adolescents according to DSM-5 criteria.

• Anxiety Disorder Interview Schedule: A structured clinical interview used to identify a range of disorders including anxiety and mood disorders in both children and adults.

The most commonly used assessment for adults is:^[10]

• Adult Separation Anxiety Questionnaire (ASA-27):A 27-item self-report questionnaire designed to assess symptoms of separation anxiety in adults.

If you think you may have developed or be suffering from separation anxiety disorder in adulthood, it is recommended to find a separation anxiety disorder or anxiety specialist either online or in your area. Be sure to ask prospective mental health professionals questions about their experience with separation anxiety disorder (specifically in adults), and to enquire how you will be assessed.

Risks and Complications

Separation anxiety disorder can lead to long-term consequences affecting academic, cognitive, psychological, social, and financial well-being. For this reason it is incredibly important to seek treatment for separation anxiety disorder, as it can wreak havoc in all of these areas, lowering quality of life satisfaction not only for the sufferer but for their loved ones too.^[2]

Educational, Occupational, and Cognitive Impairments

People with separation anxiety disorder are at higher risk for school or work absenteeism and academic or professional underachievement. Studies have also linked separation anxiety disorder to impairments in memory, spoken language, and writing skills, with more severe anxiety correlating with poorer performance.^[2]

Financial and Relationship Impact

Separation anxiety disorder limits optimal functionality and can contribute to lost productivity for both sufferers and their caregivers, partners, or children. The disorder also incurs significant financial costs due to the need for long-term treatment and reduced work performance. Additionally, separation anxiety disorder has a negative impact on forming and maintaining healthy relationships.^[2]

Suicidality and Mental Health Risks

Separation anxiety disorder is linked to other anxiety disorders, as well as Cluster C personality disorders. Fear of abandonment (a core symptom of separation anxiety disorder) overlaps with the same symptom in borderline personality disorder.^[2]

Additionally, studies suggest an approximately 10% increase in suicidal thoughts and behaviors in adolescents who have anxiety disorders, including separation anxiety disorder.

Prevention

While it may not be possible to prevent separation anxiety disorder from developing in adults who have already experienced unstable caregiving, by seeking treatment, it is possible to prevent it from getting worse. Most mental health experts agree that a child's early years lay the foundation for personality development, and that without early intervention, separation anxiety disorder may lead to other issues such as depression, and obstinacy.^[1][5]

Due to the link between mental health and attachment theory, it may be possible to prevent separation anxiety disorder from emerging in a child by taking actions that support the development of secure attachment. This is supported by a 2023 study, which shows how a child’s sense of security with their caregivers affects how much family behaviors influence their separation anxiety symptoms.^[11]

In other words, when caregivers overly accommodate a child's fears (like avoiding separations to keep them comfortable), it has a stronger link to the development of separation anxiety disorder in children who already feel less secure in their attachment to their parents. This is likely due to the fact that attachment styles have been found to affect a child’s ability to separate from caregivers.^[11]

The key difference between secure and insecure attachment styles lies in how caregivers soothe emotions. Securely attached children receive better emotional support when dealing with fear or frustration, like feeling scared of a big dog or being unable to achieve something. Over time, repeated positive emotions help children develop better coping skills.^[12]

Here are a few tips on how to build a secure attachment style with your child:

• Pay attention to your child’s emotional needs (such as seeking comfort or expressing emotions) and consistently respond with warmth.

• Encourage emotional expression by validating their feelings and helping them name and understand emotions rather than dismissing or minimizing them.

• Provide a safe and predictable home environment with clear boundaries and routines so your child feels secure and knows what to expect.

Treatment and Management

Cognitive behavioral therapy (CBT) is the main treatment for separation anxiety disorder in both children and adults. Parent training is also a useful management technique, and can help children to feel supported, gain confidence, and build independence.^[1][2]

If symptoms of separation anxiety disorder are severe or don’t improve with therapy, antidepressants may be prescribed, but these are not approved for children under the age of 6. There are also lifestyle changes that can be implemented to reduce symptoms of anxiety, including school involvement.^[1][2]

Parent Training

For children experiencing mild symptoms of separation anxiety disorder, providing education, emotional support, and reassurance to both the child and their parents can often be enough to help them regain a sense of security and return to normal daily activities.^[2]

Cognitive Behavioral Therapy

CBT helps to change negative thought patterns, ultimately lessening the anxiety response. However, up to 44% of children with anxiety do not improve with CBT alone. Exposure therapy, a type of CBT where a person is gradually exposed to their fears, may increase success rates.^[2]

Medication

The best results for treating separation anxiety disorder come from combining CBT with antidepressants known as selective serotonin reuptake inhibitors (SSRIs), with up to 81% of children responding to this approach compared to 60% for CBT alone and 55% for SSRIs alone. Anti-depressants such as SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) can help with anxiety.^[2]

Lifestyle Changes

Establishing and maintaining consistent daily routines for eating, sleeping, and physical activity is essential for managing separation disorder anxiety. Creating a predictable daily schedule can provide a sense of control, making it easier to manage anxiety and build emotional stability.^[2]

School’s Role in Managing Separation Anxiety Disorder

Separation anxiety disorder is the most common anxiety disorder in children, especially affecting those of school age. Therefore, teachers can play a major role in identifying and managing the disorder. By recognizing symptoms early, implementing predictable routines, facilitating gradual exposure, and creating a buddy system, schools can support recovery from separation anxiety disorder.^[13]

Establishing gradual exposure strategies, like allowing a parent to stay briefly during drop-off, can help ease separations and reduce anxiety. Schools can also use buddy systems, where a child with separation anxiety disorder is paired with a friendly, responsible peer, or buddy. The buddy can provide moral support during school arrival, transitions between classes, or lunch breaks.

A buddy can also offer encouragement, remind the anxious child of coping strategies (like deep breathing) and model confidence in school-related activities. For students with severe separation anxiety disorder, schools can accommodate flexible arrival times, quiet spaces for emotional regulation, or gradual reintegration plans after extended absences.

Final Thoughts

Separation anxiety can be a normal part of development in many children, while separation anxiety disorder is a disorder that causes functional impairment and requires professional support and treatment. There are strong links between abandonment issues and separation anxiety disorder, with findings suggesting that the disorder may be prevented by forming secure attachment bonds at an early age.

Although separation anxiety disorder was only diagnosed in children pre-2013, the DSM-5 now specifies that adults can meet the criteria for diagnosis as well. Research surrounding separation anxiety disorder in adults is limited, but some studies have stated that the first-line treatment for both adults and children is cognitive behavioural therapy (CBT).

However, more severe cases may require a combination of CBT and anti-depressants. Fortunately, research has shown that medicine and CBT together result in around 80% of children responding to treatment. This means there is hope for a drastic decrease in symptoms over time, as well as a reduction in the risks associated with separation anxiety disorder.