When Does Separation Anxiety Start? The Triggers and Risk Factors

What is separation anxiety?

Separation anxiety occurs when there is overwhelming fear, anxiety or distress relating to being separated from a particular person, people, or even a pet. The people they are attached to are usually a blood relative, an intimate partner, or even people they simply live with such as a roommate. 

This overwhelming fear surfaces as constant worry that impacts their lives in multiple ways, including physical ailments, sleep deprivation from nightmares, and an inability to leave the house to attend work or social activities. 

The majority of children between the ages of 18 months to 3 years old¹ will experience some level of separation anxiety; however, it will generally resolve within a few weeks. For it to be diagnosed as separation anxiety disorder (SAD), it must continue for at least four weeks and be at an unusual level and presentation for the person’s age and developmental stage.

In adults, SAD can affect all age groups; however, it’s more common in young adults as they make plans to leave home and separate from their nuclear family and support system. 

When it affects older adults, it’s usually a response to a major traumatic life event, such as a loved one passing away, grown children leaving home, or the family relocating. 

The lifetime risk of developing SAD is thought to be approximately 4.1–5.1%.² 

According to the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5), to be diagnosed with the disorder, the behaviors must be present in children and youth for at least four weeks and in adults for at least six months.  

Symptoms of separation anxiety disorder in children

In children, SAD can alter the child’s behavior and it’s these behavioral changes that can alert a caregiver. The behaviors you may witness in a child with SAD could include the following:³

• Clingy with both parents

• Excessive tearfulness in anticipation of being separated

• Constant worry about losing a parent or loved one to an accident or disaster

• A reluctance to do anything that requires them to be separate from their parents (such as attending school or sleeping alone)

• Violent or highly emotional outbursts

• Not wanting to be home alone

• Decreased school performance

• Reluctance to interact positively with other children

• Nightmares about separation

SAD can often present in the form of very real physical ailments. These may include stomachaches, headaches, or vomiting. 

What is separation anxiety in adults?

SAD in adults can create similar fears and anxieties as those prevalent in children. However, the excessive fears of separation that an adult experiences has a more “adult flavor”. 

With SAD, adults can experience a strong belief that something very bad or fatal will happen⁴ to themselves or their loved ones resulting in their separation. This fear can be so crippling that the adult creates ways to remain close to those they are attached to, and when their closeness is threatened or removed, they can experience an anxiety response such as debilitating panic attacks.

Like with children, SAD in adults can also cause physical illness such as stomachaches, headaches, pain, vomiting, or diarrhea. 

What causes separation anxiety?

The general consensus is that both environmental and genetic factors³ play a part in someone developing SAD and, interestingly, it is most often experienced by girls. 

Child separation anxiety disorder

Childhood behavioral inhibitions

When the relationship between the development of SAD and a child’s temperament are considered, it has been shown that when children generally show behavioral inhibitions, they are more likely to develop childhood SAD (CSAD). 

What do we mean by behavioral inhibitions?³ Behavioral inhibitions is a personality or temperament style. In childhood, a person with behavioral inhibitions show an increased tendency to be fearful of and withdraw from new and unfamiliar situations or people.

Unhealthy mother-child attachment

There seems to be a big focus on the mother-child relationship and, more importantly, the parental style of the mother with respect to a child’s fearfulness. In particular, when the mother has an overbearing or rejection-based parental style, the child is more likely to experience CSAD. 

The greatest effect is seen when the mother is only sporadically available for the child and is typically ambivalent to the child’s anxieties. This actually results in a feeling of trauma and loss in the child. 

Parental mental illness

The strongest link between CSAD and familial influence is when the parents have anxiety and depressive disorders. In fact, mothers, in particular, of children with SAD have an increased risk of being diagnosed with an anxiety disorder of some sort or major depression while raising the child or some time in the future. 

Children who have one or both parents living with panic disorders — with or without major depression — also have a greater chance of developing CSAD. 

Stressful environment

When the household environment is under stress through marital problems, family violence, a strained father-child relationship, a single parent, or no social support from the parents, the prevalence of CSAD is increased. 

Adult separation anxiety disorder

Until recently, onset of SAD in adulthood wasn’t categorically recognized; however, the DSM-5, by which psychiatric clinicians guide their diagnoses, now includes onset of adult SAD (ASAD) as a possible diagnosis. This is great news considering that in a study looking at ASAD in a population of people with major depressive disorder, 77.5%⁵ of participants had their symptoms of SAD first appear in adulthood. 

Traumatic event or loss

If you have experienced a traumatic event, such as loss of a loved one, where separation was either threatened or came to pass, then you may be at an increased risk of developing ASAD and become overly fearful of the same happening again. 

Overbearing or detached parent(s)/mother

As we stated above for children, if you had an overly involved mother (or parent), or an overly detached parent who was ambivalent, then you’re possibly more likely to develop ASAD through not having healthy familial relationships and support structures as a child. 

Comorbidities

If you already have another mental illness, such as anxiety or depressive disorders,  you’re more likely to develop ASAD.

How is separation anxiety disorder diagnosed?

Diagnosis is typically achieved through a comprehensive interview by a clinician following the criteria set out in the DSM-5. Typically for children, the child and parent(s) will be interviewed separately with the answers compared to help guide a diagnosis. 

A multitude of guiding screens/assessments can be used; however, they can be limiting due to the underdeveloped linguistic capabilities of children before they’re six or seven years old. 

Unfortunately, as of yet, no blood tests can be completed because no biomarkers to indicate the presence of SAD have been found. So diagnosis is still based on assessment and interview. 

The DSM-5 indicates that a child, teenager, or adult must exhibit at least three of the eight identified symptoms known to have a significant effect on the individual’s social encounters, schooling, or work performance. These symptoms have to last a minimum of four weeks in children and teenagers, and a minimum of six months in adults; and they must not be able to be explained by other causes. 

The symptoms that are typical of SAD include:

• crippling distress that comes on when real or threatened separation from one’s home or attachment figures occur

• intense and persistent fear of losing attachment figures or harm coming to them 

• intense and persistent fear of harm coming to oneself, which will cause separation from attachment figures

• frequent hesitation to leave the house and go to school or work for fear of separation

• intense and persistent fear of being alone or finding oneself away from an attachment figure 

• intense and persistent fear of sleeping away from home or at home while the attachment figure is not there 

• frequent nightmares that are consistently about separation-related scenarios 

• persistent physical ailments that come from real or threatened separation from an attachment figure 

How is separation anxiety disorder treated in children and adults?

Treatment for CSAD and ASAD are generally similar, but their application differs as the patient’s development and cognitive abilities are different. Generally, milder cases can be treated with family involvement and education, and cognitive behavioral therapy (CBT). 

In more severe cases, medication can be given to work in conjunction with other forms of therapy. Here we outline some of the differences in the application of the treatments for children and adults, and the effects of them. 

Treatment in children

Cognitive behavioral therapy

CBT has been shown to play a very important role in treating SAD in children and teenagers. Generally, it’s divided into three phases:

1. Education phase 

Children are given general information about how their anxieties typically affect them, including in bodily reactions and ailments, behavior or avoidance, and thoughts and worries. 

The children are taught relaxation strategies that may help with counteracting their bodily responses (rising blood pressure, shortness of breath, panic). 

The mantra throughout the education phase is to “face your fears”. The therapist explains to the child that by avoiding the situation of separation from their attachment figures (their parents when the child must go to school, for example), their fear is emphasized as the situation of separation and no bad event happening as a result, does not occur. Therefore, the child has no opportunity to realize that nothing bad will happen. The child is taught that exposures will be introduced in a very small and consistent way rather than all at once.

2. Application phase

This simply involves the child being exposed to the stimulus (going to school, for example) and then being supported and rewarded by the parent(s). It requires the clear and collaborative setting of the goals or rungs, and what and when the reward will come. 

3. Relapse prevention phase

The child is taught that “if you don’t use it, you lose it” and the importance of continuing to practice exposing themselves to the stimulus and accepting praise for their successes. 

Medication

Compared to CBT treatment, very little research about using medication to treat children with SAD is available. If medication is used, it should generally be only for the more resistant cases in order to ensure participation in therapy is effective. Medication is never used as a first line treatment over CBT. 

With respect to the specific medications used, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants may be effective. 

Treatment in adults

Treatment of ASAD is much like that for children using CBT and medication, however some added constructs can be helpful. 

Acceptance and commitment therapy

A growing amount of research supports the usefulness of acceptance and commitment therapy (ACT) for treating adult disorders including depression, anxiety, chronic pain, OCD, psychosis, and addictions. 

ACT is a branch of CBT that focuses on accepting thoughts and emotions as they arrive. ACT teaches the person to behave in ways that are meaningful to themselves, which leads to a fulfilled and purposeful life. 

The main purpose of ACT is to teach participants psychological flexibility, which is when they can be open and fully present in their situation even if it’s painful. Participants are then encouraged to make choices according to their individual values. Essentially, instead of controlling or avoiding fears, people are taught to embrace them and move through them. 

Dialectical behavior therapy

Dialectical behavior therapy (DBT) is another form of CBT which aims to identify and change negative thinking patterns and world views and pushes for positive behavioral changes.

The core concepts of DBT are dialectics and biosocial theory. 

Dialectics involves teaching the patient to see the world as shades of gray rather than in a traditional black and white palette. The patient is taught to recognize that reality is complex and changing and when one part changes, it influences another area of life. The patient is taught that there is no one absolute truth but rather different perspectives or responses to an event will all have an element of individual truth. 

Biosocial theory is the recognition that both biology and environment work collaboratively in developing an individual’s central nervous system (CNS), which in turn influences and regulates emotional and bodily responses in humans. Thus, if the CNS did not develop properly due to genetics, in utero development, or trauma, then a person’s ability to regulate one’s own emotions is reduced. 

Since psychiatric problems are thought to stem from learned unhealthy behaviors, and emotions, thoughts, actions and bodily responses contribute to behavior, a DBT therapist aims to help patients identify and replace beliefs and behaviors that are reinforcing their mental illness. 

Solution-focused therapy

For adults who can possibly identify a specific causal situation for their SAD, solution-focused therapy (SFT) can be useful. 

This treatment is very simple in its method; it basically aims at helping individuals be a part of their own solution by recognizing the problem or event (facing it), creating a goal of where they would like to be in their treatment, and then constructing small, measurable, and realistic steps to get there. 

How to cope with separation anxiety as an adult

Along with the therapeutic treatments we have mentioned above, which will help you deal with and come through the SAD you suffer from, a number of coping strategies are available that you could employ on an everyday basis, which have been shown to be very effective and helpful.

Mindfulness and meditation

The therapies mentioned above all require a degree of mindfulness in their approach; however, to practice this alone on an everyday basis is very helpful. Using mediation apps or yoga classes could be a good way of easing yourself into it. 

Art therapy

Creating and appreciating art to help express your thoughts, feelings, and struggles could be a very therapeutic and beautiful way of dealing with them. 

There is no right or wrong answer in art, which makes it a very freeing way of expressing yourself without fear of retribution. It can often be used by a person who is non-verbal. It’s also useful to express what you can’t find the words for. 

Art therapy includes guided sessions using sandplay, dancing, music, drama, sculpting, painting, puppeting, or writing poetry and prose. 

Journaling

Very simply, this is getting your thoughts down to be able to record your feelings about things. Don’t let the fear of pen and paper put you off if you’re not a “writer”, as many apps are available that assist with developing the practice of journaling. 

If you’re more of a “speaking” person, then this can even be done in the form of video or audio journaling. 

Exercise or yoga

Gentle exercise, such as walking or yoga, is an extremely beneficial way of dealing with chronic stress and mental illness. 

Not only do walking and yoga have physical benefits through the release of endorphins, burning of calories, and forcing you into the outdoors and fresh air, but it also gives you a chance to process your thoughts while not becoming so absorbed in them because you’re doing something active at the same time. 

The effect of separation anxiety disorder on the family and relationships

Anxiety disorders, and in particular SAD, can have a dramatic effect on families and relationships. The behaviors associated with SAD (chronic worry and stress, the need to be close and to create situations to keep attachment figures close by, lack of sleep, and reluctance to leave the house) can all create stress and difficulties for those supporting someone with SAD. 

Of course, SAD also usually goes hand-in-hand with other mental illnesses in adults which, in and of themselves, can create tensions in all types of relationships. 

Therefore, if you’re a spouse, parent, or caregiver of someone with SAD it’s important to ensure you also have your own support network and outlets to deal with the inevitable stress and tensions that arise. 

The lowdown

SAD is a difficult disorder to suffer from or live with if you provide support to someone suffering from it. SAD stems from an intense fear of being separated from loved ones. 

The effects of SAD can be huge and far-reaching on a person’s life and family unit, so it needs to be treated effectively. This is normally achieved through CBT or other forms of talk therapy, and medication as a last resort, but can also be managed through coping strategies, including exercise, a creative outlet, journaling, or meditation.