Separation Anxiety Disorder (SAD)

What is separation anxiety disorder?
Separation anxiety disorder (SAD) is a condition that causes a child to feel intense worry and fear at the idea or prospect of being away from family members, other people and even places (most commonly, his home) that he cares about.

To better understand SAD, it’s helpful to understand anxiety disorders in general. People are born with the instinctive “fight or flight” response that helps us escape predators and other threats. When we’re afraid, concerned or stressed, the part of our brain responsible for the fight or flight response generates the nervous, fearful sensation we call anxiety. While everyone experiences anxiety at times, people with anxiety disorders contend with excessive worrying that doesn’t go disappear the way normal anxiety does.

A child with an anxiety disorder can’t “just put their worries aside,” no matter how hard they try. They feel much more anxious, and for much longer periods of time, than other children do in the same situations.

What do children with separation anxiety disorder usually worry about?
Separation anxiety disorder is centered on the child’s fear or dread of being physically apart from loved ones (and sometimes places, such as home or school).

Common fears experienced by children with SAD include:

• being lost and unable to return to home or family
• being abandoned (“If mom drops me off at school, she’ll never come back”)
• something bad happening to a parent or other loved one during, or because of, the separation

The consistent factor in any worry associated with separation anxiety disorder is that the child’s fear is unrealistic. What he fears will happen is very unlikely to happen. 

While all children go through phases of “clinginess,” especially with their parents, a child is likely to have separation anxiety disorder if her feelings:

• last for at least four weeks
• are more severe than the normal separation anxiety phases most children experience (usually when they’re between 18 months and 3 years old)
• disrupt her daily life and activities

When does SAD typically emerge, and who does it affect?
Separation anxiety disorder usually begins to emerge around the third or fourth grade (between ages 8 and 10), though it can also affect younger and older children. The disorder affects boys and girls equally. 

Causes

What causes separation anxiety disorder?
Anxiety disorders like SAD are linked to biological, family and environmental factors. A chemical imbalance in the brain most likely contributes to anxiety disorders.

Anxiety and fear can be inherited, as well as learned, from family members and others who are anxious around a child. For example, a child with a parent who is afraid of leaving home may learn to fear leaving home, too. A traumatic experience may also trigger separation anxiety (for example, the sudden death of a family member).

Is separation anxiety disorder common?
About 4 percent of younger children have SAD, while the estimate for adolescents is slightly lower.

Signs and symptoms

What are the symptoms of separation anxiety disorder?
Symptoms vary from child to child, but are all focused on fear of being physically away from someone or something important to the child.

Warning signs of SAD may include:

• refusal to sleep alone
• repeated nightmares with a theme of separation
• excessive distress when separation from home or family occurs, or is anticipated
• excessive worry about the safety of a family member
• excessive worry about getting lost
• refusing to go to school
• fearfulness and reluctance to be alone
• frequent stomachaches, headaches or other physical complaints with no apparent medical cause
• muscle aches or tension
• excessive worry about safety
• excessive worry about sleeping away from home
• excessive "clinginess," even when at home
• panic attacks and/or temper tantrums at times of separation from parents or caregivers

These symptoms are likely to signify SAD if they occur for at least a month and noticeably impact your child’s daily routine and activities.

Questions to ask your doctor

You and your family play an essential role in your child’s treatment for SAD. It’s important that you share your observations and ideas with your child’s treating clinician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations. 

You’ve probably thought of many questions to ask about your child’s condition and prognosis. It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you will have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you. (If your child is old enough, you can encourage him or her to write down questions, too.)
 
Initial questions to ask your doctor might include:

• What criteria did you use in reaching a diagnosis of SAD?
• Is it possible that these symptoms could point to any other condition?
• What are the treatment goals for my child?
• How can I encourage my child to talk and ask questions about SAD?
• What role should I play in my child’s treatment?
• How do I walk the fine line between reassuring my worried child and fueling the separation anxiety?
• How should I respond if my child is in the midst of an anxious episode?
• Will you be working with my child’s other caregivers?
• How long do you expect my child to need therapy?
• How can I tell if my child is making progress?
• How should I involve my child's school in treatment?
• How should I explain my child's condition to other members of the family?
• Will you prescribe medication for my child? If so, what are the possible side effects?
• How can my family and I best support my child through treatment?
• Does anything in my child’s day-to-day routine need to change?
• How long will it take for my child to start feeling “back to normal”?
• What other resources can you point me to for more information? 

FAQ

Q: Are anxiety disorders like separation anxiety disorder common in children?
A: Yes. Anxiety disorders, including SAD, are among the most common mental, emotional and behavioral problems affecting children. According to the U.S. Substance Abuse and Mental Health Services Administration:

• about 13 out of every 100 children ages 9 to 17 experience some kind of anxiety disorder
• girls are affected more often than boys
• about half of all children diagnosed with an anxiety disorder also have a second anxiety disorder or another type of mental or behavioral disorder (such as depression) 

Q: How can I tell if my child has SAD, or is just being clingy?
A: Nearly all children experience brief periods of anxiety about being away from a parent and display clingy behavior. Typically, these normal bouts occur when a child is between 18 months and 3 years old, although older children can have passing feelings of separation anxiety at particularly stressful times.

The difference between these normal feelings of anxiety and a disorder like SAD is that a child with separation anxiety disorder will experience an extended and extensive period of fear and distress about being apart from familiar people or places, and the degree of anxiety and fear is notably out of proportion to the reality of the situation.

As an example, let’s say your child is starting his first day of kindergarten. He’s likely to show some anxiety and discomfort when getting up and ready for school and going into the school building for the first time. He may even cry when he returns home, and say he wants to stay with you and not have to leave again the next day.

If this period of anxiety is minor (he is comforted by asking you questions and receiving reassurance), lasts for only a short time (for the first couple of days or so) and is replaced by a return to his normal disposition and activities soon after, this is probably normal separation anxiety.

However, if your child remains significantly distressed about being away from you during the school day (to the point that he may feel physically ill, can’t focus on schoolwork or play and isn’t soothed by your or his teachers’ reassurance), this can be a warning sign of separation anxiety disorder.

Q: Why is psychotherapy, or “talk therapy,” so helpful in treating SAD?
A: Through scientific studies, we’ve learned that the brain is a “practice organ”—meaning that, whenever you feel a certain way and respond with a corresponding action, your brain quickly learns to correlate the feeling and the behavior. 

For children with SAD, this tendency can have a decidedly negative effect. As an example, a child might feel anxious about leaving home to sleep over at a friend’s house. In response, she may insist on staying home in order to feel that she (and possibly her family) remain “safe.” The child’s brain has now made the connection between “being afraid” and “sleeping over at a friend’s house,” so that the next time the child is faced with the prospect of a sleepover, the feelings of anxiety will be as strong, if not stronger.

Psychotherapy (“talk therapy”) is an extremely effective method of overcoming the disproportionate anxiety that is the calling card of SAD. An experienced mental health professional uses psychotherapy to help your child’s brain practice healthy responses to anxiety, replacing the damaging practices of worry and avoidance learned before. Therapy sessions teach your child:

• how to vocalize feelings of worry and fear
• techniques (such as deep breathing, counting to 10 or mentally picturing a relaxing place or scenario) for reducing the physical feelings associated with anxiety
• new thought patterns to replace the destructive ones—for example, responding to an initial sense of anxiety by remembering, “There is nothing for me to be afraid of. It’s only my brain trying to trick me into feeling scared. I will be OK.” 

Q: Why do some children need anti-anxiety medication for SAD?
A: Some children may need the additional support of medication to ease their feelings of separation anxiety to a manageable degree, so that they can begin to benefit from psychotherapy. Here at Children’s, medication is never a standalone treatment—we only prescribe it in conjunction with talk therapy. Learn more  about how Children’s prescribes psychiatric medication. 

Q: What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?
A: Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

“Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

If your child is prescribed any medication for SAD, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to address any concerns you may have. 

Q: Can I prevent my child from developing SAD?
A: While anxiety disorders like SAD can’t be prevented altogether, seeking treatment as soon as you notice that your child has a problem can help reduce the severity of the symptoms and improve your child’s quality of life.

Q: What is the long-term outlook for a child with SAD?
A: Although your child may no longer experience anxiety about being separated from loved ones or his home, it’s impossible for him to avoid feelings of anxiety in general. Since the human brain is wired for the “fight or flight” response that causes the feeling of anxiety, your child will experience periods of anxiety throughout his life, just as anyone does.

It’s possible that he will struggle from time to time with abnormal levels of anxiety due to the pre-existing tendency toward excessive worry. However, the tools learned in psychotherapy will provide your child with coping techniques to carry into adulthood, and the majority of children with SAD have substantial improvement over the long term.

Q: What if my child has been diagnosed with another mental health issue, in addition to separation anxiety disorder?
A: A child with SAD may have another mental health condition, including:

• another anxiety disorder (such as obsessive-compulsive disorder or social anxiety disorder)
• a mood disorder (such as depression or bipolar disorder)
• attention-deficit hyperactivity disorder (ADHD) 

If your child has been diagnosed with SAD as well as another mental or behavioral health problem, the conditions must be treated at the same time. Your clinician will work to develop a treatment plan that meets your child’s specific needs. 

Q: What is the most important thing I need to know about SAD?
A: If you suspect your child may have SAD, it is essential to speak with a qualified mental health professional as soon as possible. Children with anxiety disorders respond well to treatment that is administered by trained clinicians. By closely working with the treatment team, you can help your child go on to enjoy an active and fulfilling life.