Disorders of Childhood: Separation Anxiety Disorder

Children and adolescents affected by Separation Anxiety Disorder become severely distressed when separated from their familiar surroundings and caregivers. The very thought of being separated from family members may cause anxiety feelings, and actual separation leads to pronounced distress and agitation. This distress is persistent and frequent, and interferes with the child's ability to engage in normal age-appropriate activities that require temporary separation from caregivers (e.g., attending school and community-based activities).

Separation Anxiety needs to be viewed in a developmental context in order to differentiate what is normal and age-appropriate and what is disordered. The amount of distress children with Separation Anxiety Disorder experience is excessive in relation to the typical reaction a peer might have in similar circumstances. For instance, it is developmentally normal for one year olds to express some degree of distress when separated from caregivers. It is also normal for children who are just beginning daycare, preschool, or kindergarten to experience severe distress when first separated from their caregivers. Such anxiety reactions normally diminish or go away altogether within a short period of time as children become accustomed to these new environments. It is not typical for children's anxiety reactions to persist after they have been at school for a week or so. A Separation Anxiety Disorder diagnosis does not apply to developmentally normal expressions of distress upon separation from caregivers.

Children with Separation Anxiety who have been forced to leave their caregivers may become agitated and angry. They typically become preoccupied with reuniting with their caregivers. They may demand to know the location of caregivers and insist on staying in touch with them during the separation period. Children may also become preoccupied by a fear that accidents or illnesses will harm caregivers or themselves during the period of separation.

Other symptoms of Separation Anxiety include:

• Anticipatory fear over the possibility of caregiver loss, in the absence of ans reasonable evidence suggesting that loss is imminent.
• Fear at the thought of leaving home and familiar environments (e.g., for a vacation), possibly even expressed when children are accompanied by caregivers during the travel.
• Refusal to do things such as school that will cause separation from caregivers.
• Fear at the idea of doing things alone, unsupervised by caregivers.
• Clingy behavior; children may shadow caregivers throughout their day rather than play independently.
• Difficulty with separating from caregivers at bedtime (e.g., children may want a caregiver to stay with them until they fall asleep).
• Physical symptoms (e.g., stomachache, headache, or nausea) when separated or when worrying about being separated from caregivers. These physical complaints may represent a somatization of normal anxiety sensations (e.g., a reinterpretation of the psychological and subtle physical sensations associated with anxiety as purely physical sensations).
• Repeated nightmares about being separated from caregivers.

According to the DSM, at least 3 of the above symptoms must occur over a period of one month before the diagnosis of Separation Anxiety is made.