Separation Anxiety

Reviewed on 12/16/2021

Facts You Should Know About Separation Anxiety

Separation anxiety is a fairly common anxiety disorder that affects children and young adolescents. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), a child with separation anxiety experiences recurrent excessive anxiety beyond that expected for the child's developmental level. This anxiety results from separation or impending separation from the child's attachment figure (for example, primary caretaker, close family member). As defined, this condition affects children younger than 18 years of age and occurs over a period of at least four weeks.

Characteristic features of separation anxiety disorder include severe distress, fear, or worry leading to impairment of functioning and frequently accompanied by somatic symptoms such as headaches or stomachaches (see Prognosis).

What Causes Separation Anxiety?

Separation anxiety is a developmentally normal characteristic in infants and toddlers younger than 4 years of age upon separation from their primary attachment figure. Mild distress and clinging behavior are anticipated for short periods of time when young children are separated from their primary caregivers (attachment figures) in situations such as day care or initial exposure to school. Short-term developmental fears such as fear of the dark are expected in young children and are generally not severe enough to interfere with daily functioning or result in long-term difficulty.

Research studies indicate that some children who are overly fearful early in life may eventually develop anxiety disorders that result in substantial impairment. Significant symptoms of anxiety may emerge when a child enters school for the first time and is expected to adjust to daily separation from a parent or caregiver. In some cases, initial separation anxiety resolves over the first few weeks of school, while less commonly, the anxiety does not resolve spontaneously and worsens over time. Children who persist with significant anxiety disorders may have difficulty adjusting to the classroom leading to compromised academic performance.

Researchers have hypothesized that children who develop separation anxiety disorders may have altered sensitivity to endocrine influences such as maternal cortisol, and the way in which they process emotionally intense experiences of separation. It is well known that certain parts of the brain (such as the amygdala) are involved in modulating the processing of emotional experiences.

Bullying and experiences of recurrent social rejection may contribute to the development of separation anxiety in vulnerable children and adolescents.

What Are Symptoms and Signs of Separation Anxiety?

Symptoms of separation anxiety disorder include the following:

  • Subjective feeling of anxiety
  • Unrealistic worries about the safety of loved ones
  • Reluctance to fall asleep if not near the primary attachment figure
  • Excessive dismay (for example, tantrums) if separation from the primary attachment figure is imminent
  • Nightmares with separation-related themes
  • Homesickness
  • Psychosomatic symptoms such as:

When to Seek Medical Care for Separation Anxiety

Seek medical evaluation when social functioning becomes impaired, that is when a child or adolescent is refusing to go to school, is not socializing, is avoiding participation in sports or recreation, or is unwilling to be separated from the primary caregiver.

Questions to Ask the Doctor about Separation Anxiety

  • Can you perform an evaluation to determine if my child is socially isolated due to anxiety or depression?
  • Can you perform or refer for a family assessment?
  • How can the child be supported in the school environment to prevent secondary school refusal?
  • What other tests should be performed to rule out other causes of anxiety symptoms?

What Exams and Tests Do Medical Professionals Use to Diagnose Separation Anxiety?

The following structured and semistructured interview scales, administered by a medical professional, can be extremely helpful for the diagnosis and treatment of separation anxiety disorder:

  • The Anxiety Disorders Interview Schedule for Children (ADIS)
  • The Anxiety Rating Scale for Children (Revised)
  • Multidimensional Anxiety Scale for Children (MASC) - Duke University
  • Revised Children's Manifest Anxiety Scale
  • Visual Analogue Scale for Anxiety (Revised)
  • Interview Schedule for Anxiety Disorders for DSM-IV (Child Version)
  • Social Anxiety Scale for Children (Revised)
  • Diagnostic Interview for Children and Adolescents Revised (DICA-R)
  • National Institute of Mental Health Diagnostic Interview Schedule for Children (DISC)
  • Child Behavior Checklist (Achenbach ASEBA)
  • The Screen for Child Anxiety Related Emotional Disorders (SCARED) - Western Psychiatric Institute and Clinic (WPIC)
  • The Separation Anxiety Test (Wash U)

A physical exam with clinically pertinent medical testing should be performed, preferably by the primary-care physician. Tests may be performed to rule out metabolic abnormalities (for example, hyperthyroidism, hypoglycemia), cardiovascular abnormalities, or central nervous system infections because they may cause symptoms of acute anxiety that, in children, might appear to be separation anxiety.

What Are Separation Anxiety Treatment Options?

The child or adolescent and his or her family, school staff, and primary-care physician should work together to design a plan to accomplish a gradual return to developmentally expected function in settings such as school, sports, and social events. It is very important to acknowledge the level of distress that the child or adolescent feels.

Utilizing positive reinforcement aids in encouraging the child's return to the feared situation and becoming comfortable with anticipated brief separations from parents and caregivers.

Cognitive-behavior therapy, including response prevention and exposure therapy has been shown to be effective, especially in helping the child or adolescent return to normal daily function.

Antianxiety medications may be effective but are not U.S. Food and Drug Administration (FDA)-approved for people younger than 18 years of age.

What Are Separation Anxiety Home Remedies?

Developing a routine of self-directed relaxation exercises, including breathing routines of about five to six deep and slow breaths during periods of discomfort, may be beneficial in reducing anxiety symptoms; however, avoiding continuous deep breathing leading to hyperventilation is important.

What Is the Medical Treatment for Separation Anxiety?

Medical treatment should include treating any contributory medical causes of anxiety if present.

What Are Medications for Separation Anxiety?

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and fluvoxamine (Luvox), sertraline (Zoloft), and benzodiazepines such as alprazolam (Xanax) may be helpful in reducing anxiety; however, the FDA has not approved these agents for use in children to treat separation anxiety disorders. In children and adolescents who may have coexisting depression along with anxiety, there is concern that suicidal thoughts or behaviors may be increased with the use of SSRIs when used for depression (see Understanding Antidepressant Medications). This increased risk can be assessed with regular monitoring by a mental health professional.

Other Therapy for Separation Anxiety

Gentle exercises that encourage relaxation, such as meditation or yoga or tai chi, may be helpful in reducing anxiety symptoms. In older children and teenagers, mindful meditation can be especially helpful.

Follow-up for Separation Anxiety

The child's progress in regaining normal function should be closely monitored. Factors that discourage the child from returning to health, such as family stressors, should also be explored. The therapist's approach to a child with separation anxiety should be low-key and expectations should progress at a pace that does not increase the child's anxiety.

Is It Possible to Prevent Separation Anxiety?

Techniques such as modeling, role-playing, relaxation techniques, and positive reinforcement for independent functioning can be helpful in preventing young children from developing crippling symptoms associated with separation anxiety.

What Is the Prognosis for Separation Anxiety?

Helping children with separation anxiety to identify the circumstances that elicit their anxiety (upcoming separation events) is important. A child's ability to tolerate separations should gradually increase over time when he or she is gradually exposed to the feared events. Encouraging a child with separation anxiety disorder to feel competent and empowered, as well as to discuss feelings associated with anxiety-provoking events promotes recovery.

Children with separation anxiety disorder often respond negatively to perceived anxiety in their caretakers, in that parents and caregivers who also have anxiety disorders may unwittingly confirm a child's unrealistic fears that something terrible may happen if they are separated from each other. Thus, it is critical that parents and caretakers become aware of their own feelings and communicate a sense of safety and confidence about separations.

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What is Anxiety?

What Causes Anxiety?

Problem anxiety may be caused by a mental condition, a physical condition, the effects of drugs, or from a combination of these. The doctor's initial task is to see if your anxiety is caused by a medical condition. Conditions as varied as anemia, asthma attack, infection, drug intoxication or withdrawal, or a number of heart conditions are just a few examples of medical problems that can be associated with anxiety.

Reviewed on 12/16/2021
Medically reviewed by Margaret Walsh, MD; American Board of Pediatrics


"Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course."