What Is Separation Anxiety?

Any parent who has handed over a reluctant child to a caregiver has seen separation anxiety in action. Separation anxiety is a condition in which a person feels extreme fear or distress when separated from an emotional attachment, such as a parent, a loved one, or a place they feel safe, like their home. While the tears can be heartbreaking, the good news is separation anxiety is a normal part of child development and usually gets easier with time. 

When separation anxiety occurs in older children, adolescents, or adults, or when it causes debilitating anxiety, it is considered separation anxiety disorder (SAD). Unlike typical separation anxiety, SAD is intrusive and may require treatment such as behavioral therapy, other psychotherapies, positive reinforcement, or medications, depending on the person’s age and the severity of their symptoms. 

Some symptoms of SAD overlap with symptoms of panic disorder and other types of anxiety disorders. If you suspect you or your child has SAD, it’s a good idea to see a healthcare provider to get a nuanced and accurate diagnosis.

What Is Separation Anxiety?

Have you ever wondered why babies love peek-a-boo? It all has to do with object permanence. Before a baby develops object permanence, things (and people) really are “out of sight, out of mind.” 

At about the age of 8 months, babies develop a sense of selfhood and begin to learn object permanence but don’t quite fully comprehend its complexities. They know they exist separate from other people, and they understand that a parent or loved one exists even after they have left their presence, but they aren’t always convinced their beloved person is coming back. 

This normal developmental stage usually starts when a baby is about 8 months old and can last until a child is 3 or 4 years old.

This anxiety can rear its head even if the child knows and trusts the person in whose care they have been placed. Ask any childcare provider, and they will tell you how frequently a child will cry when dropped off, then quickly settle in once their parent has left.

As a child matures emotionally, and begins to trust that people who leave come back, separation anxiety tends to resolve on its own. 

While separation anxiety is a normal part of development in young children, it is not considered typical in older children, teens, and adults. When separation anxiety occurs in people outside of early childhood and has a negative impact on the individual’s well-being, social functioning, family life, academic or work performance, and physical health, it may be regarded as SAD.

Accounting for 50% of diagnoses in children seeking treatment for mental health, SAD is the most common pediatric anxiety disorder. By adolescence, roughly 8% of youth have met diagnostic criteria for SAD at some point in their lives.

Though we tend to associate separation anxiety with children, some research suggests that at some point in their lives, up to 6.6% of adults will experience SAD.

Symptoms

Every child has meltdowns, even older children. 

The occasional emotional outburst does not indicate SAD. SAD is characterized by persistent and extreme emotions and behaviors both with separation and in anticipation of separation from a major attachment figure such as a parent or grandparent, from home, or both.

Common symptoms of SAD include:

• Distress related to separation
• Excessive worry about losing or harm coming to the attachment figure
• Worry that an event will cause a separation from the attachment figure
• Reluctance or refusal to go to places such as school
• Fear of being alone or without the attachment figure
• Reluctance to sleep away from the attachment figure
• Nightmares about separation
• Physical symptoms associated with separation

SAD can manifest in physical symptoms, including:

• Headaches
• Stomachaches
• Nausea
• Vomiting 
• Bed-wetting

School is a major stressor for older children with SAD. An older child or adolescent may exhibit school-specific behaviors like feigning illness or experiencing headaches, stomachaches, and other ailments when it is time to go to school. These illnesses go away once the child is allowed to stay home but reappear before school the next day. 

They may refuse to go to school or to say goodbye, or they may have “meltdowns” involving prolonged screaming and crying.

For older children, SAD symptoms are not limited to times of separation. SAD can manifest in a number of ways even when the child is home and/or with their parent or loved one. Older children with SAD may:

• Feel anxious being alone in a room
• Be “clingy”
• Worry excessively about something happening to themselves, their parents, or their loved ones
• Stay close to parents, even within the home
• Have exaggerated and irrational fears of things like the dark, monsters, or burglars
• Have difficulty sleeping

While for children, the attachment figure is usually a parent or guardian, for adults it may be a spouse, a partner, or a friend. 

Adult separation anxiety disorder (ASAD) can be debilitating. ASAD can cause problems with job performance, including lack of concentration, coming in late or leaving worry, or difficulty maintaining employment. 

People with ASAD may also have difficulties with social and romantic relationships. Often, the subject of the attachment becomes distressed or annoyed by the neediness of the person with ASAD. Sometimes what we call “drama” is a person exhibiting symptoms of ASAD.

ASAD may manifest when a person is dealing with the breakdown of a relationship or the death of a loved one. A parent may even suffer from ASAD when their child becomes more independent and no longer relies solely on them for companionship.

Diagnosis

If your child is still experiencing separation anxiety past the age of 3 or 4 when it is developmentally normal, SAD may be the culprit. When suspected, SAD is usually diagnosed after the age of 6 or 7. 

For a diagnosis of SAD, both adults and children must meet three of the eight conditions outlined in the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM 5); however, the assessment tools differ by age.

To be diagnosed with SAD, children must show symptoms for at least four weeks. To meet the criteria for a SAD diagnosis, adults must experience symptoms that impair function for at least six months.

To diagnose adults with SAD, healthcare providers primarily rely on self-reports. Because children cannot reliably be assessed with adult self-reports, parents and healthcare providers must use other methods.

The Children’s Separation Anxiety Scale (CSAS) lists child-accessible questions such as, “Does your belly hurt when you have to leave your mom or dad?”, and “Do you worry about getting lost?” that can help a healthcare provider assess if a child is experiencing symptoms of SAD.

Parents can play a big part in their child’s assessment by relaying observations they have made of their child. A healthcare provider may ask parents to note their observations in a structured document known as a Separation Anxiety Daily Diary (SADD).

Causes

While scientists don’t fully understand what causes SAD, they believe it is related to biological, cognitive, and environmental factors.

Environment

SAD symptoms often appear after a change or stress in a child’s life. Even a positive change can cause a child to feel anxious. Some changes that might trigger or exacerbate SAD include:

• A change in caregiver
• A change in routine
• A traumatic event
• A change in parental availability or discipline
• A change in family structure, such as divorce or separation, a death, birth of a sibling, or parental illness
• Illness
• Lack of adequate rest
• A family move
• Starting a new school, or returning to school after time away

Parental Mental Health

• Data suggests that SAD is 20 to 40% heritable, meaning that it can be inherited from a biological parent. This suggests that a child is more likely to develop SAD if they inherit certain temperamental and anxious vulnerabilities from their parents.

Parenting Style

Parenting style is linked to attachment theory—how our early experiences with attachment affect our mental health and our ability to bond with other people.

SAD appears to be associated with attachment anxiety—anxiety experienced about relationships with people who are important in our lives.

Parenting that is overly critical, overly controlling, or overprotective can interfere with a child’s development of autonomy, and contribute to anxiety disorders. The effects of parenting style are seen both in childhood and after a person enters adulthood.

Temperament

Children with SAD do not like change. When something is new or different, they tend to react negatively and respond with avoidance, fear, or suspicion. They can also have a difficult time self-regulating their emotions when they feel anxious or scared. 

Adults with SAD try to avoid confrontation. They also tend to lack self-directedness—the ability to be goal-oriented, resourceful, and adaptive to situations.

Economics

How socioeconomic status (SES) affects childhood anxiety is complex and depends on a number of factors including the type of anxiety, and if income is evaluated at an individual household level or a neighborhood level.

Most children with anxiety disorders come from middle- to upper-income families. In contrast to this, those with SAD tend to come from low-income homes. This suggests that financial stresses within a family may lead to insecurity in younger children.

Treatment

Contingency Management

This treatment is based on positive enforcement. The child and the parent agree on a set of goals. When the child meets the goals, the parent gives them a reward. The reward can be anything the child finds valuable, be it a sticker, a toy, or even extra TV time. Contingency management operates on the principle that behaviors that get rewarded get repeated.

Cognitive Behavioral Therapy (CBT)

The first go-to treatment for SAD is CBT. Studies show it to be an effective treatment for anxiety disorders including SAD, without the side effects that can come with medication.

CBT focuses on the “here and now” rather than the underlying cause of the condition. The goal of CBT is to change learning and thought patterns that are unhealthy or cause problems and replace them with ones that are adaptive and productive.

With CBD, it isn’t just the child whose approach and behavior needs to change. Parents, teachers, and other significant figures in the child’s life need to commit to changing their responses to the child’s anxiety, reinforcing the child’s progress.

Treatment usually takes twelve to sixteen weeks but may require “refresher” sessions here and thereafter treatment has finished.

Exposure Therapy

Exposing children to the very things that scare them sounds counter-productive, or even mean. In reality, exposure therapy works on the principle that confronting your fears gives you the chance to see that they are innocuous, and helps you develop coping strategies to manage your anxieties. This probably sounds familiar. Does it call to mind the “face your fears” speeches given to most of us by our own parents?

Exposure therapy is more controlled than simply not running away from things that scare us. Treatment usually falls into four phases, worked through in order.

1. Instruction: Adults, or children with SAD and their parents, are given a detailed overview of exposure therapy, including its goals, how it works, and what can be expected. The idea of exposure therapy can be frightening, and this is a chance to put minds at ease.
2. Development of a hierarchy: A series of anxiety-inducing experiences are created, and arranged from least anxiety-provoking to most. There need to be enough entries on the list to create a gradual increase in anxiety. Jumping from a little bit anxious to panic-inducing is not good for anyone!
3. Exposure proper: This step involves exposing the person with SAD to the anxiety-provoking situations outlined in the hierarchical list, starting with the one that causes the least anxiety. Sometimes the therapist models the exposure and response before the person with SAD attempts it. Direct exposure is preferred, but not always feasible. If the exposure can’t happen in-person, imagery and virtual reality can be used.
4. Generalization and maintenance: Homework time! In this stage, the therapist assigns activities to do at home to reinforce the skills learned in the therapy session, and repeat exposures in similar situations outside of the therapy office. Exposure outside of therapy removes the association of the office with successfully facing anxious situations.

Exposure therapy is considered successful once the person with SAD has worked through all of the situations on the list, and has reduced their anxiety to appropriate levels for their age and development.

Medications

While selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in treating SAD, due to the potential of side effects and the lack of availability for FDA approved SSRIs available for children under six, medication is rarely prescribed as the first-line treatment to children with SAD. It may be administered if first-line treatments such as CBT are not effective.

For adults, SSRIs may be prescribed on their own, but they are more effective as part of a combination therapy. Although this can vary, they are typically taken for six months then gradually tapered off.

Coping

Whether developmentally normal separation anxiety or SAD, separation can be hard on young children and their parents. To make the transition easier for young children, parents can:

• Make it a quick goodbye: Always say goodbye to your child before leaving. Sneaking away teaches children that you can disappear at any time without warning. But make those goodbyes quick, even if your child is upset. Staying longer reinforces the anxiety and its response, and coming and going again after you have left is confusing and disruptive. Say a quick goodbye and go – your child’s caregiver will thank you!
• Be consistent: Routines are comforting for all children, but particularly anxious ones. Try to keep your child’s drop off routine consistent and predictable. Your child will feel less anxious if they know what to expect.
• Follow through: If you make a promise to your child, keep it. Developing trust with your child helps them believe you when you say you are coming back.
• Use terms your child understands: Your child has no concept of time according to a clock. 5:00 means nothing to them, but “after snack time” does. If you will be away from your child for a number of days, use “sleeps” to indicate the amount of time you will be gone and when you will return.
• Practice: Leave your child for a short time with someone they know and trust, like Grandma. Leave the room for a few minutes during a playdate, letting your friend watch your child. Schedule an orientation with your child’s daycare before they start to become familiar with the new surroundings and to practice saying goodbye and coming back. Remember to say goodbye, even when it’s just for practice.

Having a healthy attachment with a parent or parents helps greatly when it comes to both separation anxiety and SAD. To encourage a secure attachment  from the start, foster a supportive, safe, and dependable environment for your baby or young child. Children who feel secure have an easier time exploring new places and experiences.

Object permanence is the beginning of preparing for time away from your child. You can help develop your child’s understanding and trust in object permanence by playing simple games.

• Play “leave and return”: Leave the room and come back. Talk to your child from another room, out of their sight. Seeing you regularly leaving and returning helps your child understand that you are not gone for good just because they can’t see you.
• Peek-a-boo: Cover your face, then uncover it, excitedly saying “peek-a-boo!”
• Hiding objects: Hide a toy under a blanket, ask your child where it is, then pull the blanket off to reveal the toy was under there the whole time. Try it again by hiding a toy somewhere else and finding it.

For adolescents and adults living with SAD, it may be helpful to follow coping strategies for anxiety.

• Social coping strategies: Participate in social activities, connect with family and friends, and ask for support when you need it or reach out to an anxiety support group.
• Emotional coping strategies: Practice mindfulness, learn your triggers, and practice acceptance.
• Physical coping strategies: Take care of your body by eating well, exercising, and getting enough sleep.

A Word From Verywell

If you are the parent of a baby or young child who is experiencing separation anxiety, try to remind yourself that while difficult, it is absolutely normal and developmentally appropriate. Like all difficult stages, this too shall pass.

If your older child or teen—or you—develop SAD, breathe easier knowing that help is available. With proper treatment, SAD can become a thing of the past.

If you or your child are struggling with SAD, contact the Substance Abuse and Mental Health Administration (SAMHSA) National Hotline for treatment and support group referrals at 1-800-662-HELP (4357).