Separation Anxiety
There is now a lifespan approach to SepAD, as reflected in the change in diagnostic criteria in ICD 11 (1) and DSM V (2). A review of the evidence base pertaining to adults is currently underway and will be added to this topic information in Autumn/Winter 2024.
*Note on abbreviations: Separation Anxiety Disorder and Social Anxiety Disorder are both commonly abbreviated to SAD within the research literature. For the purposes of the Matrix, the abbreviation SepAD is used to refer to Separation Anxiety Disorder.
Separation anxiety disorder is characterised by marked and excessive fear or anxiety about separation from specific attachment figures (1). The symptoms will have persisted over several months and the classification of a disorder is associated with significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. In line with a lifespan approach, ICD-11 (1) identifies Separation Anxiety Disorder (SepAD) as a condition that can present in children adolescents or adults.
In children and young people (CYP) the focus of the separation anxiety tends to be caregivers, parents or other family members, and the fear or anxiety around separation is beyond what would be considered developmentally normative. In adults, the focus is typically a romantic partner or children. Symptoms of SepAD may include thoughts of harm or untoward events befalling the attachment figure, reluctance to go to school or work, recurrent excessive distress upon separation, reluctance or refusal to sleep away from the attachment figure, and recurrent nightmares about separation (1).
Separation anxiety in CYP as a disorder should be distinguished from the common transient, adaptive or developmentally normal experience of anxiety resulting from separation from an attachment figure (3-5). These symptoms typically present between 7 and 12 months, peaking at 15–18 months and reducing between the ages of 3-4 (6,7) and are understood to have the adaptive purpose of protecting young children from danger (8). Assessment of SepAD should consider cultural norms and differentiate from developmentally normal or adaptive anxieties (1,5). Clinical assessment within a developmental context should differentiate SepAD from other explanations such as: an adaptive response to ongoing stressors within the CYP’s life; a response within the context of another mental health problem; an acute stress reaction; a response to trauma or an uncomplicated bereavement (1). Parents or caregivers are likely to be involved in the assessment and treatment given the developmental stage of many CYP presenting with SepAD and the focus of the anxiety.
Difficulties associated with SepAD can result in significant distress with impact upon personal, family, social and educational functioning and developmental tasks (1,9). A high proportion of CYP with SepAD also experience difficulties attending school, compounding the potential impact of SepAd across academic, emotional and social development and longer-term outcomes (10,11).
SepAd persists into adulthood for 36% of those with childhood onset (12) and experiencing SepAD in childhood may increase vulnerability to mental health difficulties such as anxiety, behavioural and mood disorders in later adolescence and early adulthood (1,13-15). SepAD in CYP frequently co-occurs with other anxiety disorders (16-18) , depression (17,18) and externalizing disorders (17-19). Higher rates of SepAD have also been identified in CYP with attention-deficit/hyperactivity disorder (ADHD) (1,16,19).
SepAD is one of the earliest mental health problems to emerge(20), with typical onset during childhood, at the transition to school or emerging in middle childhood (1,3,6,12,20,21). Reported prevalence rates in CYP community samples vary from 1% to 6% (22-26). This includes a community sample of CYP in Northern Ireland aged 2-19 with an estimated 5.2% prevalence rate (22). Higher prevalence rates are identified during childhood as compared with adolescence in both clinical and community samples (23-25,27); Copeland et al (21) report community prevalence rates of 4.5% at ages 9– 10 years reducing to approximately 1% at ages 11– 12 years, and within clinical samples, Waite & Creswell (27) report rates of 19% of children and 4% of adolescents as presenting with SepAD. The lifetime prevalence rate for SepAD is slightly higher among females (5.6% versus 4%). During childhood school refusal is equally prevalent in girls and boys (1).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with SepAD. This information is also for children, young people and adults diagnosed with SepAD, their families, and carers.
This topic page currently covers evidence-based psychological interventions for the management of SepAD in children and young people, and the psychological practice and settings in which these interventions can be delivered. A review of the evidence base pertaining to adults is now underway and ultimately this page will cover the lifespan. There are no published clinical guidelines in this area. This section does not cover pharmacological interventions or interventions which are not informed by psychological theory. It does not include other anxiety disorders.
It is recommended that this section is read in conjunction with the GAD and good practice section for delivering psychological therapies and interventions with children and young people.
Overview of Evidence for Children and Young People
The evidence base for CYP CBT interventions often comprises transdiagnostic protocols with mixed and co-morbid anxiety disorders, including SepAD. Evaluation of psychological intervention for CYP presenting with only SepAD is limited. The Matrix GAD section offers a comprehensive overview of psychological interventions aimed at treating mixed anxiety disorders in CYP.
Evidence indicating that persistent high levels of separation anxiety throughout early years may increase vulnerability to SepAD, and as SepAD represents one of the earliest mental health disorders to emerge (5,20), mental health promotion along with preventative and early intervention are indicated e.g. approaches supporting parents in negotiating normative developmental experiences (28,29) (see also Solihull Approach and Early Intervention Framework). Child parent relationship therapy is recommended for use with preschoolers and younger children.
CBT based interventions including individual CBT, group CBT, CBT informed programmes delivered in school, parent-led CBT and computerised CBT with practitioner support were all identified as potentially effective interventions for CYP with SepAD. Interventions aimed at removing maintenance factors by including parent-sessions are identified as efficacious, especially among younger children.
Interventions principally involving parents or caregivers such as child-parent relationship therapy or parent-led CBT are likely to be more appropriate for younger children (see Matrix CYP Good Practice Guide).
Decisions as to most appropriate intervention will be informed by the setting of the intervention e.g. school or clinic, age and developmental stage of the CYP and the presence of co-occurring conditions. The table contains information pertaining to individual, group and parent-led interventions.
NB: Combined parent and child interventions refer to interventions where the focus is direct work with the CYP and parental involvement ranges from joint parent and CYP sessions, additional parent-only sessions and parental attendance at the start and end of each session.
|
Recommendation |
Who for? |
List of interventions |
Type of psychological practice |
Evidence |
Efficacy |
|
First line recommendation |
Transdiagnostic anxiety in school age CYP |
Individually delivered: Guided self-help for CYP with parental involvement (30). Computerised CBT with practitioner support for CYP with parental involvement (31). Computerised CBT with practitioner support delivered to parents (32). |
Skilled/Enhanced |
A | Large |
|
First line recommendation |
Transdiagnostic anxiety in school age CYP |
Individual CBT with parental involvement (33). |
Specialist |
A | N/A |
|
First line recommendation |
Sep AD in school age CYP |
Individual CBT with parental involvement (33). |
Specialist |
A | N/A |
|
First line recommendation |
Transdiagnostic anxiety in school age CYP |
Parent-Led CBT (32,34). |
Enhanced |
A | N/A |
|
First line recommendation |
Transdiagnostic anxiety in school age CYP |
Group CBT with parental involvement (33). |
Specialist |
A | N/A |
|
Alternative |
School age CYP both with anxiety and at risk of developing anxiety. |
School-based prevention and intervention group programmes based on CBT principles (35,36). |
Skilled/Enhanced |
B |
N/A |
(1) World Health Organisation. ICD-11 for Mortality and Morbidity Statistics: 6B05 Separation anxiety disorder. 2019; Available at: https://icd.who.int/browse/2024-01/mms/en#830200631. Accessed April 22, 2024.
(2) DSM 5 American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™. 5th ed.: American Psychiatric Publishing, Inc.; 2013.
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(27) Waite P, Creswell C. Children and adolescents referred for treatment of anxiety disorders: differences in clinical characteristics. J Affect Disord 2014;167:326–332.
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(32) Creswell C, Taylor L, Giles S, Howitt S, Radley L, Whitaker E, et al. Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and northern Ireland: A pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomised controlled trial. The Lancet Psychiatry 2024;11(3):193–209.
(33) Giani L, Caputi M, Forresi B, Michelini G, Scaini S. Evaluation of Cognitive-Behavioral Therapy Efficacy in the Treatment of Separation Anxiety Disorder in Childhood and Adolescence: a Systematic Review of Randomized Controlled Trials. J Cogn Ther 2022 03/;15(1):57–80.
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(35) Rodgers A, Dunsmuir S. A controlled evaluation of the 'FRIENDS for Life' emotional resiliency programme on overall anxiety levels, anxiety subtype levels and school adjustment. Child Adolesc Ment Health 2015 -02;20(1):13–19.
(36) Orgilés M, Garrigós E, Espada JP, Morales A. How does a CBT-based transdiagnostic program for separation anxiety symptoms work in children?: Effects of Super Skills for Life. Revista de Psicología Clínica con Niños y Adolescentes 2020;7(2):9–15.