Separation Anxiety Disorder

Separation anxiety disorder is developmentally inappropriate, excessive fear of separation from attachment figures lasting at least 4 weeks in children and 6 months in adults.

• Prevalence 4% in children, 1 to 2% in adults; peak at 7 to 9 years.
• Risk factors: parental anxiety, overprotection, life stressors (bereavement, school change), behavioural inhibition.
• Comorbid other anxiety disorders, depression, ADHD; may precede panic disorder.
• Adult form affects relationships and work.

• Distress on separation, school refusal, fear of harm to parents, nightmares, refusal to sleep alone.
• Somatic complaints (headache, abdominal pain, nausea) on school mornings, clinging, tantrums.
• Adults: excessive calling, fear for partner or children, difficulty travelling.

• Clinical interview with child and parents; Screen for Child Anxiety Related Disorders (SCARED); school information.
• Exclude generalised anxiety, social anxiety, bullying, depression, PTSD, school avoidance from learning difficulties, and medical causes of recurrent abdominal pain.
• Assess family functioning and safety.

• CBT adapted for age with parent involvement (exposure, coping skills), and parent training to reduce accommodation, is first line.
• Gradual school return with school support.
• Medication for moderate to severe or CBT nonresponse: sertraline 25 to 200 mg daily or fluoxetine 10 to 40 mg daily in children (start lowest dose, monitor for activation and suicidal thoughts); adults: sertraline 50 to 200 mg daily or escitalopram 10 to 20 mg daily.
• Avoid benzodiazepines in children.
• Address family stressors and parental anxiety.