SEPARATION ANXIETY DISORDER: SYMPTOMS, CAUSES, AND TREATMENTS - ARTE - 2025

The separation anxiety disorder is a disorder that is characterized by excessively high levels of anxiety when the child is separated from his parents. It is one of the most common psychopathologies that occur during childhood.

Suffering from this disorder during childhood usually causes a lot of discomfort in the child, who at some point or another will be forced to separate from his parents, in addition, it is also usually a difficult problem for his parents to manage.

In this article we will explain the characteristics of separation anxiety, we will review what its possible causes may be and what strategies must be carried out to treat it properly.

What is separation anxiety?

In general, most children experience certain levels of anxiety, nervousness and discomfort whenever they are separated from their parents, especially if they are separated from both and their care is in the hands of other people.

However, this fact by itself does not explain the presence of separation anxiety disorder, and these children's responses are considered normal and adaptive.

In this way, separation anxiety (SA) is considered an emotional response in which the child experiences anguish when physically separating from the person with whom they have an emotional bond, that is, with their maternal and / or paternal figures.

This anxiety experienced by children is considered a normal and expected phenomenon, which is subject to the children's own development, and to their psychological and social characteristics.

Normally, a child, from 6 months of age, begins to manifest this type of anxiety every time he is separated from his parents, since he already has a sufficiently developed mental structure to link the figure of his parents to feelings of protection and security.

In this way, the discomfort that the child experiences from being separated from his parents is understood as an adaptive response in which the child, in anticipation of not being able to protect himself adequately without the help of his parents, responds with anguish and anxiety when they are separate from him.

Thus, this separation anxiety allows the child to gradually develop his ability to be alone and to modulate the attachment relationship he has with his parents.

As we can see, the delimitation of separation anxiety disorder can be more complicated than expected, since its main characteristic (separation anxiety) can be a totally normal phenomenon.

Thus, the appearance of separation anxiety should not always be automatically related to separation anxiety disorder, that is, experiencing this type of anxiety does not always constitute a psychological disorder of childhood.

We are going to define the characteristics of separation anxiety disorder to clarify a bit what this psychological alteration refers to.

Separation anxiety disorder (SAD) is a psychopathological manifestation characterized by the inability of the child to stay and be alone.

Thus, a child with separation anxiety disorder differs from a child who simply suffers from separation anxiety by being unable to properly separate from the person with whom they have a significant emotional bond.

This fact can be confusing, but it is manifested mainly by the presentation of anguish and excessive anxiety about what would be expected for the child's level of development.

Thus, the main difference between a child with separation anxiety disorder and a child who does not is based on the fact that the former experiences excessive anxiety over what would be expected based on their developmental level, and the latter does not.

Obviously, quantifying what type and what levels of anxiety are appropriate for a child when separated from their parents is a rather complicated task and one that can be controversial.

What level of anxiety corresponds to each stage of a child's development or each stage of childhood to be considered normal?

To what extent can experiencing anxiety in a 3-year-old be considered normal? And in a child of 4? Should it be different?

All these questions are difficult to answer, since there is no manual that specifies what type of anxiety all 3-year-olds should manifest equally or what type of anxiety those with 7 should manifest.

Likewise, there are multiple individual differences, as well as multiple factors that can appear and modulate the appearance of symptoms.

Will it be the same if the child is separated from his parents but stays with the grandfather, a person with whom he also lives, as if he is separated from the parents and is left in the care of a "babysitter" that he does not know?

Obviously, both situations will not be comparable, so attempts to quantify anxiety to establish whether it is normal or pathological may be useless.

In order to clarify what separation disorder is and what a normal separation reaction is, we will now specify the characteristics of both phenomena.

Variable	Separation anxiety (AS)	Separation anxiety disorder (SAD)
Age of appearance	Between 6 months and 5 years.	Between 3 and 18 years old.
Evolutive development	The anxiety experienced is consistent with the child's mental development and has an adaptive character	Anxiety is disproportionate depending on the level of mental development of the child
Intensity of anxiety	The expression of parental separation anxiety is of similar intensity to that which occurs in other stressful situations for the boy.	The expression of parental separation anxiety is of great intensity and greater than the anxiety expressed in other situations.
Thought	Ideas of harm or death in relation to attachment figures are less intense and more tolerable.	The child has multiple disturbing and relevant thoughts that something catastrophic will happen to the parents and they will be harmed irreversible or even death.
Attachment styles	Secure attachment style, proper and harmonious bonding.	Insecure attachment style, inappropriate and disharmonious bonding.
Reaction of the dyad to separation	The mother-child dyad is harmonious and calm in the face of separation.	The mother-child dyad is stressed and over-activated in the face of separation situations.
Functioning	Anxiety does not interfere with the normal functioning of the child even though he may be more tense than usual.	Anxiety greatly interferes with the normal functioning of the child.
Scholarship	There is no school refusal and if there is it is transitory.	There may be an obvious and often insurmountable school refusal.
Forecast	Tendency to regression and spontaneous remission of anxiety symptoms.	Separation anxiety appears in childhood and tends to last for years, even into adulthood.

Diagnosis

As we have seen, there are several differences that make it possible to distinguish normal separation anxiety from separation anxiety disorder.

In general, SAD is differentiated by witnessing excessively high and cognitively inappropriate anxiety states according to the child's mental development.

Likewise, separation anxiety disorder appears after the age of 3, so the separation anxiety that is previously experienced can be considered a relatively normal phenomenon.

In addition, SAD is characterized by producing a cognitive alteration through disproportionate thoughts about possible misfortunes that may happen to their parents, as well as producing a clear deterioration in the child's functionality.

At a specific level, the criteria according to the DSM-IV-TR diagnostic manual that are required to make a diagnosis of separation anxiety disorder are the following.

A. excessive and inappropriate anxiety for the subject's level of development, concerning his separation from home or from the people with whom he is linked. This anxiety is manifested through a minimum of 3 of the following circumstances:

Recurrent excessive discomfort when a separation occurs or is anticipated with respect to the home or the main related figures.

Excessive and persistent concern about the possible loss of the main related figures or that they suffer possible damage.

Excessive and persistent concern that an adverse event will lead to the separation of a related figure (eg being kidnapped).

Persistent resistance or refusal to go to school or anywhere else for fear of separation.

Persistent or excessive resistance or fear of being at home alone or in the main linked figure.

Persistent refusal or resistance to going to sleep without having a related figure nearby or going to sleep outside the home.

Repeated nightmares with the theme of separation.

Repeated complaints of physical symptoms (such as headaches, abdominal pain, nausea, or vomiting) when separation occurs or is anticipated.

B. The duration of the disorder is at least 4 weeks.

C. Onset occurs before 18 years of age.

D. The disturbance causes clinically significant distress or impairment in the child's social, academic, or other important areas.

E. The disturbance does not occur exclusively in the course of pervasive developmental disorder, schizophrenia, or other postpsychotic disorder, and in adults it is not better explained by the presence of panic disorder with agoraphobia.

Causes

Currently, there seems to be no single cause that leads to the development of SAD, but rather a combination of different factors.

Specifically, 4 factors have been identified that seem to play an important role in the development of this psychopathology.

1. Temperament

It has been shown how inhibited character and behavior can increase the risk of developing anxious pathology.

In general, these characteristics have a high genetic load, especially in girls and advanced ages. Therefore, in children and young infants, environmental factors may play a more important role.

2. Attachment and regulation of anxiety

Attachment constitutes all those behaviors that the person performs with the aim of seeking proximity with other people considered stronger and safer.

Thus, according to the theoretical perspective of attachment, the ability of parents to respond adequately to the child's needs would be a fundamental aspect to establish a secure attachment and prevent the child from experiencing separation anxiety disorder.

3. Family system

A study by Weissman showed that children raised in families with parents with anxious and overprotective styles had a higher risk of SAD.

4. Neurobiological findings

A study carried out by Sallee found that dysregulation of the norepinephrine system is strongly related to the development of excessive anxiety, so that alterations in brain function could explain the presence of SAD.

Treatment

To treat a separation anxiety disorder, it is very important first to properly carry out the diagnostic process.

Normal separation anxiety can often be confused with a SAD, and while psychological treatment may be very appropriate for the latter, it is not for the former.

Once the diagnosis is made, it is convenient to treat SAD through psychosocial and pharmacological interventions.

Psychotherapy is the treatment of first choice for this type of problem, since controlled studies have shown how cognitive behavioral therapy is highly effective in intervening this type of problem.

This treatment can be both individual and group, as well as involving the parents in the therapy.

Psychotherapy is based on carrying out an affective education so that the child learns to identify and understand his anxiety symptoms, apply cognitive techniques to restructure distorted thoughts about separation, train the child in relaxation and gradually expose him to the feared situations.

Pharmacological treatment should only be used in cases of very severe anxiety with which psychotherapy has failed to mitigate the symptoms.

The drugs that can be used in these cases are selective serotonin reuptake inhibitors (SSRIs), especially fluoxetine, a drug that has shown efficacy and safety in the treatment of anxiety problems in children.

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV). Ed. Masson, Barcelona 1995.
2. Barlow D. and Nathan, P. (2010) The Oxford Handbook of Clinical Psychology. Oxford University Pres.
3. Leckman J, Vaccarino FM, Lombroso PJ: Development of the symptom of anxiety. In: Child and Adolescent Psychiatry: A Comprehensive Textbook (3rd ed.) Lewis M (Ed.), Williams & Wilkins, 2002.
4. Weissman MM, Leckman JE, Merikangas KR, Gammon GD, Prusoff BA: Depression and anxiety disorders in parents and children: results from the Yale Family Study. Arch Gen Psychiatry 1984; 41: 845-52.
5. Sallee FR, Sethuraman G, Sine L, Liu H: Yohimbine challenge in children with anxiety disorders. Am J Psychiatry 2000; 157: 1236-42.

VE Horse. (1997). Manual for the cognitive-behavioral treatment of psychological disorders. Vol. I. Anxiety, sexual, affective and psychotic disorders i Vol. Clinical formulation, behavioral medicine and relationship disorders, II. Madrid: 20th century.