Separation anxiety disorder is a disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment (e.g., a parent, a caregiver, a significant other, or siblings) called the attachment figure. It is most common in infants and small children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents, and adults.

Separation anxiety is a natural part of the developmental process. Unlike separation anxiety disorder (indicated by excessive anxiety), normal separation anxiety indicates healthy advancements in a child’s cognitive maturation and should not be considered a developing behavioral problem.

According to the APA, separation anxiety disorder is an excessive display of fear and distress when faced with situations of separation from the home and/or from a specific attachment figure. The anxiety that is expressed is categorized as being atypical of the expected developmental level and age. The severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation. Individuals with separation anxiety disorder demonstrate avoidance behaviors. Individuals “typically exhibit excessive distress manifested by crying, repeated complaints of physical symptoms (e.g., stomachaches, headaches, etc.), avoidance (e.g., refusing to go to school, to sleep alone, to be left alone in the home, to engage in social events, to go to work, etc.), and engagement in safety behaviors (e.g., frequent calls to or from significant others, or primary caregivers).”^[1]

Separation anxiety disorder may cause significant negative effects within areas of social and emotional functioning, family life, and physical health of the disordered individual.

Diagnosis of Separation Anxiety Disorder

The duration of this problem must persist for at least four weeks and must present itself before a child is eighteen years of age to be diagnosed as a separation anxiety disorder in children, but can now be diagnosed in adults with a duration typically lasting six months in adults as specified by the DSM-5.

As mentioned, separation anxiety is normal in young children, until they age three to four years, when children are left in a daycare or preschool away from their parent or primary caregiver. To be diagnosed with separation anxiety disorder, one must display at least three of the following criteria:

• recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures
• persistent and excessive worry about losing major attachment figures or about possible harm to oneself, such as illness, injury, disasters, or death
• persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure
• persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation
• persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings
• persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure
• repeated nightmares involving the theme of separation
• repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated

Epidemiology of Separation Anxiety Disorders

Anxiety disorders are the most common type of psychopathology to occur in today’s youth, affecting from 5%-25% of children worldwide. Of these anxiety disorders, separation anxiety disorder accounts for a considerable proportion of diagnoses. Separation anxiety disorder may account for up to 50% of the anxiety disorders as recorded in referrals for mental health treatment.^[2] Separation anxiety disorder is noted as one of the earliest-occurring of all anxiety disorders. Adult separation anxiety disorder affects roughly 7% of adults.

Research suggests that 4.1% of children will experience a clinical level of separation anxiety and 1.6% of adolescents. Of that 4.1%, it is calculated that nearly a third of all cases will persist into adulthood if left untreated. Research continues to explore the implications that early dispositions of separation anxiety disorder in childhood may serve as risk factors for the development of mental disorders throughout adolescence and adulthood. A higher percentage of children are presumed to suffer from a small amount of separation anxiety and are not actually diagnosed. Multiple studies have found higher rates of separation anxiety disorder in girls than in boys, and that paternal absence may increase the chances of separation anxiety disorder in girls.

One of the difficulties in the identification of separation anxiety disorder in children is that it is highly comorbid with other behavioral disorders, especially generalized anxiety disorder. Behaviors such as refusal or hesitancy in attending school or homesickness, for example, can easily reflect similar symptoms and behavioral patterns that are commonly associated with separation anxiety disorder but could be an overlap of symptoms. The prevalence of co-occurring disorders in adults with separation anxiety disorder is common and includes a much broader spectrum of diagnostic possibilities. Common comorbidities can include specific phobias, PTSD, panic disorder, obsessive-compulsive disorder, and personality disorders.^[3]

Causes of Separation Anxiety Disorder: Risk Factors and Biological and Environmental Contributions 

Factors that contribute to the disorder include a combination and interaction of biological, cognitive, environmental, child temperament, and behavioral factors.

Children are more likely to develop separation anxiety disorder if one or both of their parents was diagnosed with a psychological disorder.^[4] Recent research by Daniel Schechter and colleagues have pointed to difficulties of mothers who have themselves had early adverse experiences such as maltreatment and disturbed attachments with their own caregivers, who then go on to develop responses to their infants’ and toddlers’ normative social bids in the service of social referencing, emotion regulation, and joint attention, which responses are linked to these mothers own psychopathology (i.e., maternal post-traumatic stress disorder (PTSD) and depression.)^[5] These atypical maternal responses, which have been shown to be associated with separation anxiety, have been related to disturbances in maternal stress physiologic response to mother-toddler separation as well as lower maternal neural activity in the brain region of the medial prefrontal cortex when mothers with and without PTSD were shown video excerpts of their own and unfamiliar toddlers during mother-child separation versus free-play.^[6]

Many psychological professionals have suggested that early or traumatic separation from a central caregiver in a child’s life can increase the likelihood of them being diagnosed with separation anxiety disorder, school phobia, and depressive-spectrum disorders. Some children can be more vulnerable to separation anxiety disorder due to their temperament, for example, their level of anxiety when placed in new situations.

Environmental Causes

Most often, the onset of separation anxiety disorder is caused by a stressful life event, especially a loss of a loved one or pet, but can also include parental divorce, change of school or neighborhood, natural disasters, or circumstances that forced the individual to be separated from their attachment figure(s). In older individuals, stressful life experiences may include going away to college, moving out for the first time, or becoming a parent.

Genetic and Physiological Causes

There may be a genetic predisposition in children with separation anxiety disorder. Experts say, “Separation anxiety disorder in children may be heritable. . . . Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher rates in girls.”^[7]

A child’s temperament can also impact the development of separation anxiety disorder. Timid and shy behaviors may be referred to as “behaviorally inhibited temperaments” in which the child may experience anxiety when they are not familiar with a particular location or person.

Treatment

Non-Medication Based Treatment

Non-medication based treatments are the first choice when treating individuals diagnosed with separation anxiety disorder. Counseling tends to be the best replacement for drug treatments. There are two different non-medication approaches to treat separation anxiety. The first is a psychoeducational intervention, often used in conjunction with other therapeutic treatments. This specifically involves educating the individual and their family so that they are knowledgeable about the disorder, as well as parent counseling and guiding teachers on how to help the child. The second is a psychotherapeutic intervention when prior attempts are not effective. Psychotherapeutic interventions are more structured and include behavioral, cognitive-behavioral, contingency, psychodynamic psychotherapy, and family therapy.

Behavioral therapies are types of non-medication based treatment that mainly consists of exposure-based techniques. These therapies include techniques such as systematic desensitization, emotive imagery, participant modeling, and contingency management. Behavioral therapies carefully expose individuals by small increments to slowly reduce their anxiety over time and mainly focuses on their behavior. Exposure-based therapy works under the principle of habituation that is derived from learning theory. The core concept of exposure therapy is that anxiety about situations, people, and things do not go away when people avoid the things that they fear, but rather, the uncomfortable feelings are simply kept at bay. In order to effectively diminish the negative feelings associated with the situation of fear, one must address them directly.

With separation anxiety disorder, the child may be encouraged to gradually separate from their caregiver (gradual exposure). They may begin by imagining this separation, work toward increasing separation within the therapy setting, and then progress to separating in real-world situations (e.g., school). In order to administer this treatment, the therapist and the anxious child might sit together and identify progressively intense situations. As each situation is dealt with masterfully, the child advances to the next phase of intensity. This pattern continues until the child is able to handle being away from their parent in a developmentally typical way that causes them and their caregiver(s) minimal amounts of stress. While there is some controversy about using exposure therapy with children, it is generally agreed upon that exposure therapy in the context of separation anxiety disorder is acceptable as it may be the most effective form of therapy in treating this disorder and there is minimal risk associated with the intervention in this context.

Cognitive-Behavioral Therapy for Children

CBT focuses on helping children with separation anxiety disorder reduce feelings of anxiety through practices of exposure to anxiety-inducing situations and active metacognition to reduce anxious thoughts.

According to Kendall and colleagues, there are four components that must be taught to a child undergoing CBT:^[8]

• recognizing anxious feelings and behaviors
• discussing situations that provoke anxious behaviors
• developing a coping plan with appropriate reactions to situations
• evaluating the effectiveness of the coping plan

In the application phase, individuals can take what they know and apply it in real-time situations for helpful exposure. The most important aspect of this phase is for the individuals to ultimately manage themselves throughout the process. In the relapse prevention phase, the individual is informed that continued exposure and application of what worked for them is the key to continual progress.

A study investigated the content of thoughts in anxious children who suffered from separation anxiety as well as from social anxiety or generalized anxiety. The results suggested that cognitive therapy for children suffering from separation anxiety (along with social anxiety and generalized anxiety) should be aimed at identifying negative cognition of one’s own behavior in the threat of anxiety-evoking situations and to modify these thoughts to promote self-esteem and ability to properly cope with the given situation.

Cognitive procedures are a form of treatment found to be ideal for older children with separation anxiety disorder. Cognitive procedures utilize techniques that the child’s dysfunctional thoughts, attitudes, and beliefs are what lead to anxiety and cause anxious behavior. Children who are being treated with cognitive procedures are taught to ask themselves if there is evidence to support their anxious thoughts and behaviors. They are taught coping thoughts to replace previously distorted thoughts during anxiety-inducing situations, such as doing a reality check to assess the real danger of a situation and then to praise themselves for handling the situation bravely. Examples of such disordered thoughts include polarized thinking, overgeneralization, filtering (focusing on negative), jumping to conclusions, catastrophizing, emotional reasoning, labeling, “shoulds”, and placing blame on self and others. Sometimes therapists will involve parents and teach them behavioral tactics such as contingency management.

Relaxation training is another way to combat anxiety. Similar to that in exposure-based treatment for phobias, prior to engaging in exposure training, the individual must learn a relaxation technique to apply during the onset of panic attacks. Deep breathing (control, slow, and purposeful breathing) and distraction (focusing on alternative things, grounding oneself to their senses) are commonly used strategies.

Contingency Management

Contingency management is a form of treatment found to be effective for younger children with separation anxiety disorder. Contingency management revolves around a reward system with verbal or tangible reinforcement requiring parental involvement. A contingency contract is written up between the parent and the child that entails a written agreement about specific goals that the child will try to achieve and the specific reward the parent will provide once the task is accomplished. When the child undergoing contingency management show signs of independence or achieve their treatment goals, they are praised or given their reward. Contingency management facilitates a new positive experience with what used to be filled with fear and anxiety. Children in preschool who show symptoms of separation anxiety disorder do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of separation anxiety disorder.

Medication

The use of medication is applied in extreme cases of separation anxiety disorder when other treatment options have been utilized and failed. However, research has been difficult to prove the benefits of drug treatment in patients with separation anxiety disorder because there have been many mixed results. Despite all the studies and tests, there has yet to be a specific medication for separation anxiety disorder. Medication prescribed for adults from the Food and Drug Administration (FDA) are often used and have been reported to show positive results for children and adolescents with separation anxiety disorder.

There are mixed results regarding the benefits of using tricyclic antidepressants (TCAs), which include imipramine and clomipramine. One study suggested that imipramine is helpful for children with school phobia who also had an underlying diagnosis of separation anxiety disorder. However, other studies have also shown that imipramine and clomipramine had the same effect of children who were treated with the medication and placebo. The most promising medication is the use of selective serotonin reuptake inhibitors (SSRI) in adults and children. Several studies have shown that patients treated with fluvoxamine were significantly better than those treated with a placebo. Research has shown decreasing anxiety symptoms with short-term and long-term use of the medication.

Selective Mutism

Selective mutism (SM), also known as situational mutism, is an anxiety disorder in which a person normally capable of speech cannot speak in specific situations or to specific people if triggered. Selective mutism usually co-exists with social anxiety disorder. People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism, or punishment.

Selective mutism is characterized by the following:^[11]

• The consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) persists despite speaking in other situations.
• The disturbance interferes with educational or occupational achievement or with social communication.
• The duration of the disturbance is at least one month (not limited to the first month of school).
• The failure to speak is not due to a lack of knowledge of the spoken language required in the social situation.
• The disturbance is not better accounted for by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively in people with autism spectrum disorders or psychotic disorders such as schizophrenia.

Selective mutism is strongly associated with other anxiety disorders, particularly social anxiety disorder. In fact, the majority of children diagnosed with selective mutism also have social anxiety disorder (100% of participants in two studies and 97% in another). Some researchers, therefore, speculate that selective mutism may be an avoidance strategy used by a subgroup of children with social anxiety disorder to reduce their distress in social situations.

Particularly in young children, selective mutism can sometimes be confused with an autism spectrum disorder diagnosis, especially if the child acts particularly withdrawn around their diagnostician, which can lead to incorrect diagnosis and treatment. Although people with autism may also be selectively mute, they often display other behaviors—hand flapping, repetitive behaviors, social isolation even among family members (not always answering to name, for example)—that set them apart from a child with selective mutism. Some people with autism may be selectively mute due to anxiety in social situations that they do not fully understand. If mutism is entirely due to autism spectrum disorder, it cannot be diagnosed as selective mutism as stated in the last item on the list above.

The former name elective mutism indicates a widespread misconception among psychologists that selective mute people choose to be silent in certain situations, while the truth is that they often wish to speak but are unable to do so. To reflect the involuntary nature of this disorder, the name was changed to selective mutism in 1994.

The incidence of selective mutism is not certain. Due to the poor understanding of this condition by the general public, many cases are likely undiagnosed. Based on the number of reported cases, the figure is commonly estimated to be one in 1,000, or around 0.1%.

Etiology

There are many theories to frame how children develop selective mutism across different psychological domains. Several are presented in the following table:^[12]

Treatment

Treatment for selective mutism may rely on psychodynamic/play therapy, behavioral therapy, family therapy, or medications (most often antidepressants). Early treatment may help prevent the self-reinforcement of selective mutism. Self-modeling is a treatment method in which a child with the disorder is videotaped being asked questions by someone (such as a teacher), that they will not answer. Then they are videotaped and asked the same questions by a parent or someone they are comfortable speaking to, this time eliciting a verbal response. The two videos of the conversations are then edited together to show the child directly answering the questions posed by the teacher or other adult. This video is then shown to the child over a series of several weeks, and every time the child sees him- or herself verbally answering the teacher/another adult, the tape is stopped and the child is given positive reinforcement.

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