Separation Anxiety Disorder (SAD)

The Nature & Prevalence of Separation Anxiety Disorder

Image courtesy of mehrabaani.com Opens in new window Separation Anxiety Disorder (SAD) is diagnosed when developmentally inappropriate and excessive anxiety emerges related to separation from home or major attachment figures.

These days, youngsters worry, and not just about environmental dangers. School performance, social problems, or health-related issues can easily become daily preoccupations.

In large-scale community surveys, as many as 41% of children and adolescents reported separation concerns. The most frequent and highest rated concerns reported involved personal safety and injury (56%), being alone (26%), and sleeping alone (51%).

Primary symptoms of SAD include excessive worry about potential harm to oneself (e.g., being kidnapped, killed, or abandoned) or major attachment figures (e.g., heart attack, serious accident, death), fears and distress on separation, repeated complaints of such physical symptoms as headaches and stomachaches when separation is anticipated, and nightmares related to separation issues.

According to the text revision of 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR Opens in new window), separation anxiety disorder requires the presence of at least three symptoms related to excessive worry and separation from the major attachment figures (see Table X1).

Youngsters may avoid situations that lead to separation from primary caregivers and/or safe places. Common situations that culminate in separation related worries (i.e., calamitous events to self or others; getting sick) include having to go to school, be alone, sleep alone, or be dropped off at a friend’s house or social event (e.g., party).

Youngsters may resort to oppositional behaviors (e.g., temper tantrums Opens in new window, screaming, pleading threats) when avoidance of the dreaded scenario becomes unlikely. As a result, parental accommodations (i.e., allowing youngsters to avoid) are common and ultimately can strengthen the separation anxiety response.

Natural History and Course

Prevalence estimates for SAD in community samples range from 3 to 13% for children and from 1.8 to 2.4% for adolescents. SAD onset is most common during childhood (ages 7–12 years), with marked declines of onset during mid-adolescence and young adulthood.

Nevertheless, SAD continues to affect individuals throughout the lifespan. For example, in a sample of college students SAD was associated with adjustment problems, eating disorders, and the onset and maintenance of depressive disorders. In child and adolescent anxiety disorder clinics SAD has been found to be as high as 47%.

In general, SAD tends to be observed more frequently in girls than boys. However, boys may be more likely to be brought to mental health professionals. The nature of separation anxiety symptoms (e.g., fear of being alone) may be viewed as more socially undesirable in boys, thus prompting families to seek help more readily.

Rates and Patterns of Comorbidity

Anxious youth frequently present for treatment with comorbid disorders. In fact, 79% were found to have at least one other disorder. In this section of the literature, we review the co-occurrence of SAD with other anxiety disorders, depression, school refusal behavior, and behavioral and learning disorders.

1. Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) co-occurs in youngsters who have SAD approximately one-third of the time. This finding is not surprising, given that both disorders are associated with frequent worry and somatic complaints. By definition, however, the focus of worry in GAD is not limited to calamitous events to self or others, and its course is more chronic in nature.

Separation anxiety may develop subsequent to GAD, if a youngster’s experiences (e.g., a car accident involving a parent) or perceptions (e.g., neighborhood robbery) threatens his or her personal safety. When the disorders co-occur, SAD should be the initial focus of treatment if the threat of being alone or abandoned accounts for the greatest interference in functioning.

2. Obsessive-Compulsive Disorder

Recent research also reports the co-occurrence of obsessive-compulsive disorder (OCD) and SAD in children and adolescents. Although prevalence estimates for these two disorders typically range between 4 and 7%, rates for SAD have been found to be as high as 24-34% in patients with OCD. The combination of OCD and SAD is also associated with an earlier onset of panic disorder.

Clinically, youngsters with both SAD and OCD may avoid being alone due to preoccupation with images of harm to themselves or others. OCD is associated with compulsions to neutralize the anxiety, whereas SAD is associated with excessive need of safety signals (e.g., safe persons, objects). When the disorders co-occur, features of both can be targeted concurrently. If the OCD is too severe, however, negotiating SAD as a first step may help build the momentum for managing the OCD symptoms.

3. Panic Attacks

Although panic disorder (PD) typically emerges during young adulthood, panic attacks may be observed in children and adolescents with SAD. For example, in one study antecedent or associated separation anxiety was reported in 73% of youngsters (ages 7–18 years) who had panic attacks.

In addition, a number of case reports has suggested that children, in general, may experience cued panic symptoms. However, these occasional, discrete experiences should be differentiated from PD, which involves recurrent panic attacks, uncued by the environment, as well as worries about having additional attacks (American Psychiatry Association, 1994).

Concern regarding the implication of panic attacks (e.g., fear of dying, losing control) is generally not characteristic of children younger than 12 years of age. Hence, panic attacks in youngsters tend to be associated with physical (e.g., stomachaches, hyperventilation) rather than cognitive manifestations of anxiety. Separation-induced panic attacks tend to be associated with fears of abandonment and/or getting sick.

Using structured interviews and questionnaires, prevalence estimates for PD in adolescence range from less than 1% to greater than 10%, respectively. The most common symptoms reported include heart palpitations, trembling, dizziness, difficulty breathing, sweating, chest pain, and fear of dying.

4. Other Anxiety Disorders and Depression

Other anxiety disorders likely to coexist with SAD include social (8.3%) and specific phobias (12.5%). Youngsters who meet diagnostic criteria for posttraumatic stress disorder (PTSD) Opens in new window may also experience separation anxiety symptoms (e.g., refusing to be alone, school refusal behavior). However, such symptoms would be considered part of a PTSD diagnosis.

Given the association between anxiety Opens in new window and depression Opens in new window in children, it’s not surprising to find that SAD is frequently comorbid with depression. Approximately one-third of youngsters experience both SAD and a depressive disorder.

5. School Refusal Behavior

School refusal behavior is highly comorbid with SAD. In fact, as many as 75% of children with SAD may also experience some form of school refusal behavior. In most cases, however, the school refusal behavior is acute, limited to mild forms (e.g., pleas to stay home, visits to nurse), and may not necessitate treatment.

Alternatively, chronic school refusal behavior is less likely to be associated with SAD. Rather, depression, panic, and agoraphobia, as well as other incapacitating conditions are often evident. Careful assessment can help distinguish the function(s) of school refusal behavior.

6. Behavioral and Learning Disorders

Behavioral disorders are also likely to coexist with SAD. For example, ADHD Opens in new window (16.7%), oppositional defiant disorder Opens in new window (16.7%), and enuresis Opens in new window (8.3%) were found to be the most frequent comorbid disorders with SAD. Youngsters with a learning disorder (LD) are at risk for experiencing anxiety, depression, poor academic performance, and low self-esteem.

The presence of an LD may further diminish a youngster’s perception of control. When an LD co-occurs with SAD, strong safety needs often emerge.

Diagnostic and Differential Diagnosis

The assessment strategy will depend upon the child’s age, symptom profile, the sources of available information, and the purpose of the assessment. Interestingly, separation anxiety is normal at some ages and is maximal around 14 months of age.

The most prevalent symptoms in young children (aged 5–8 years) are worry about losing or about possible harm to an attachment figure (e.g., parent, guardian, or caregiver), and reluctance or refusal to go to school.

Children aged 9–12 years most frequently report recurrent excessive distress when separated from home or attachment figures, whereas adolescents (aged 13–16 years) have physical symptoms on school days. More symptoms are reported with decreasing age.

There exists a large number of self-report questionnaires that can assess children’s fears and anxieties, either to detect anxiety disorders in community samples or to distinguish between different anxiety disorders in clinically referred children. The most useful of these are the Multidimensional Anxiety Scale for Children (MASC) and the Screen for Child Anxiety Related Emotional Disorders (SCARED).

These have been shown to have good test-retest reliability, internal consistency, and can differentiate not only anxious children from nonanxious children but also distinguish specific anxiety disorders from each other. Particularly with younger children, there is value to direct observation of the child either in determining the diagnosis or in behavioral analysis.

Differential diagnoses to consider include Generalized Anxiety Disorder (GAD), where the anxiety is more free floating, less situation-specific, and occurs independent of separation from the primary attachment figure. Children with social phobia Opens in new window will display a fear of social situations where they may be the object of public scrutiny. This anxiety may be ameliorated by the presence of a familiar person but will not occur exclusively when the attachment figure is absent, as with separation anxiety.

School refusal has long been associated with SAD, though this relationship holds mainly for youngsters when school nonattendance is most closely linked to fear of separation, whereas in adolescents fear of school and other social situations in which they feel they are being evaluated is more typical.

It is important in the assessment of school nonattendance, a frequent impairment associated with SAD, to distinguish anxiety-related school refusal from conduct disorder-related truancy. Typically the school-refusing child will stay at home or with parents, whereas the truanting child will go off with peers.

In the presence of school refusal, a useful approach is to attempt to categorize the behavior as fulfilling one of the four following functions:

1. avoidance of stimuli provoking specific fearfulness or anxiety (e.g. separation)
2. escape from aversive social or evaluative situations (e.g. social phobia)
3. attention-getting behavior (e.g. physical complaints/tantrums)
4. positive tangible reinforcement (e.g., parental collusion).

Key Symptom Dimensions

Separation anxiety may be best understood by examining several key symptom dimensions that may account for separation-related symptoms individually or in combination and include fear of being alone (FBA), fear of abandonment (FAb), fear of physical illness (FPI), and worry about calamitous events (WCE).

The first two dimensions directly capture the avoidance component of separation anxiety. The common fears associated with being along and being abandoned are presented in Table X2.

1. Fear of Being Alone

Youngsters may be afraid to be left alone in certain areas of the house and therefore become the parent’s shadow. Keep in mind that, in most cases, the FBA is strong even when a family member remains somewhere in the house.

Daytime fears may include being alone in any room in the house or being on a different floor from other family members. At times, youngsters may be able to tolerate being alone if distracted by schoolwork, reading, television, or video games. Sometimes, however, distraction is not enough, especially if the entertainment system is in a more remote region of the house (e.g., finished attic or basement).

It is often easier for youngsters to be alone during the day than at night. Refusal to sleep alone is our most common referral. Youngsters who are afraid to sleep alone tend to have difficulty being alone during their nighttime routine as well. This may include going to the bathroom to brush their teeth or take a bath/shower, or simply settling down in their bedroom. As a result, bedtime may become a nightmare for the entire family.

If a youngster’s separation anxiety is limited to FBA, his or her social and academic functioning outside of the home is typically unaffected. As long as the youngster is in the company of others, his or her perception of control generally remains intact. Compared to FBA, FAb tends to wield a broader influence and is more likely to threaten the nature of a youngster’s academic and peer relationships.

2. Fear of Abandonment

Youngsters who fear abandonment may avoid certain places unless promised close proximity to a parent or major caregiver; for example, they may refuse to take the school bus or to be dropped off at a play date, extracurricular activity, birthday, party, or sleep-over.

During the preschool years, a parent may routinely stay with his or her youngster during these events. However, as elementary school progresses and greater independence from family members is expected, it become the norm for youngsters to separate from parents.

Youngsters with FAb may fiercely protest any parental attempts to force separation, and/or they may make excuses to avoid attending the events on their own. Social isolation is often the result of if avoidance becomes routine.

FAb may also have untoward effects at home. For example, youngsters may vehemently protest being left with a babysitter or resist a parent’s efforts to run an errand. Unlike FBA, having family members present (e.g., older siblings) is not enough to quell a youngster’s anxiety. Rather, the fear is specifically directed at the primary caregiver and the possibility of not being remitted with him or her.

3. Somatic Complaints/Fear of Physical Illness

The second set of dimensions—FPI and WCE—help to maintain a youngster’s separation anxiety. The common somatic complaints/fears and worries associated with separation anxiety are prescribed in Table X3.

Epidemiological surveys have suggested that between 10 and 30% of children and adolescents report frequent headaches, stomachaches, and muscle/joint pain. The ubiquity of somatic complaints has also been demonstrated in samples of children with childhood anxiety disorders, in general, and SAD, in particular.

For youngsters with separation anxiety, somatic complaints are usually in response to anticipated separations and will decrease when the threat of separation is removed.

Sometimes the physical symptoms are exaggerated to gain attention or postpone separation. In general, however, it is not the experience of the somatic complaints, per se, but what they represent that maintains the youngster’s separation anxiety. For example, a stomachache or nauseous feeling upon separation may trigger the fear of getting sick.

Although the youngster’s fear may be limited to one or two somatic sensations (e.g., vomiting, choking) and there may not be evidence of cognitive symptoms (e.g., fear of dying, losing control), the youngsters may avoid situations or places that trigger these somatic cues. This dynamic, termed “interoceptive avoidance”, is characteristic of panic disorder in adults.

As children get older and cognitive belief systems begin to develop, FPI may become associated with heightened anxiety sensitivity. Youngsters with elevated AS worry about the consequences of their bodily sensations. AS is associated with separation anxiety, school refusal behavior, and panic attacks. FAb, however, tends to be maintained by a youngster’s worry about calamitous events to others.

4. Worry about Calamitous Events

Common worries in youngsters include harm to self (e.g., being kidnapped, killed, or abandoned) or others (e.g., heart attack, serious accident, death). WCE may maintain FBA, especially if youngsters are worried about bad things happening to them at home (e.g., getting sick, burglar intrusion).

As Youngsters venture out to the world, however, WCE (to others) typically maintains FAb. For example, a fear of not getting picked up at school is often fueled by a fearful preoccupation with possible catastrophic injury to the primary caregiver.

Any sign of lateness on the caregiver’s part may easily spiral a youngster’s anxious apprehension. As a result, youngsters will often avoid a variety of separation-related situations unless promised close proximity to the caregiver. When separation does occur, as is inevitable, these youngsters are convinced that disaster has been averted only after reunion.

Safety Signals

Given the nature of separation anxiety symptoms, it’s not surprising that youngsters cling to safe persons, places, transitional objects, or actions during anticipated separations. Safety signals help individuals feel more secure and may lead to the perception of restored personal control in anxiety-provoking situations. Common safety signals associated with separation anxiety are presented in Table X4.

Safety signals are frequently present across the dimensions of separation anxiety and related disorders and can easily allay a youngster’s anxious apprehension.

For example, regarding FBA, being with others augments the youngter’s perception of personal safety (e.g., help is available if physical sickness develops) and minimizes preoccupation with the potential occurrence of calamitous events to self or others. Transitional objects (e.g., “blankie”) and favorite acitivites (e.g., watching television, playing video games) also enhance a youngster’s feelings of security when caregivers are unavailable.

Overall, it is important to keep in mind that safety signals can serve useful functions (e.g., as a lucky charm, so to speak) and at times may be considered developmentally appropriate.

At the same time, however, excessive reliance on safety signals may serve to strengthen a youngster’s separation anxiety (i.e., through avoidance behavior) and thereby result in a limited range of functioning in social and academic areas.

The gradual elimination of unhealthy safety signals coupled with the learning of new coping strategies are considered integral to facilitating successful treatment outcome in separation-anxious youth.