A. Excessive anxiety concerning separation from those to whom the child is attached, as manifested by at least three of the following:
- unrealistic worry about possible harm befalling major attachment figures or fear that they will leave and not return
- unrealistic worry that an untoward calamitous event will separate the child from a major attachment figure, e.g., the child will be lost, kidnapped, killed, or be the victim of an accident
- persistent reluctance or refusal to go to school in order to stay with major attachment figures or at home
- persistent reluctance or refusal to go to sleep without being next to a major attachment figure or to go to sleep away from home
- persistent avoidance of being alone in the home and emotional upset if unable to follow the major attachment figure around the home
- repeated nightmares involving theme of separation
- complaints of physical symptoms on school days, e.g., stomachaches, headaches, nausea, vomiting
- signs of excessive distress upon separation, or when anticipating separation, from major attachment figures, e.g., temper tantrums or crying, pleading with parents not to leave (for children below the age of six, the distress must be of panic proportions)
- social withdrawal, apathy, sadness, or difficulty concentrating on work or play when not with a major attachment figure
B. Duration of disturbance of at least two weeks.
D. If 18 or older, does not meet the criteria for Agoraphobia.
Normal separation anxiety
In early childhood some degree of separation anxiety is a normal phenomenon. Clinical judgment must be used to distinguish this from the clearly excessive reaction to separation seen in Separation Anxiety Disorder.
In Overanxious Disorder and Avoidant Disorder of Childhood or Adolescence anxiety is not focused on separation.
In Pervasive Developmental Disorder or Schizophrenia anxiety about separation may occur, but is viewed as due to these conditions rather than as a separate disorder.
In Major Depression occurring in children, the diagnosis Separation Anxiety Disorder should also be made when the criteria are met for both disorders, since it is difficult to know which condition should be regarded as the primary disorder.
In Conduct Disorder truancy is common, but the child stays outside of the home and anxiety about separation is usually not present.
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
- recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
- persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
- persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
- persistent reluctance or refusal to go to school or elsewhere because of fear of separation
- persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
- persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
- repeated nightmares involving the theme of separation
- repeated complains of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
B. The duration of the disturbance is at least 4 weeks.
C. The onset is before age 18 years.
D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia.
- Early Onset: if onset occurs before age 6 years
This specifier may be used to indicate onset of the disorder before age 6 years.
Separation anxiety can be an associated feature of Pervasive Developmental Disorders, Schizophrenia, or other Psychotic Disorders. If the symptoms of Separation Anxiety Disorder occur exclusively during the course of one of these disorders, a separate diagnosis of Separation Anxiety Disorder is not given.
Separation Anxiety Disorder is distinguished from Generalized Anxiety Disorder in that the anxiety predominantly concerns separation from home and attachment figures. In children or adolescents with Separation Anxiety Disorder, threats of separation may lead to extreme anxiety and even a Panic Attack. In contrast to Panic Disorder, the anxiety concerns separation from attachment figures or from home rather than being incapacitated by an unexpected Panic Attack. In adults, Separation Anxiety Disorder is rare and should not be given as an additional diagnosis if the separation fears are better accounted for by Agoraphobia in Panic Disorder With Agoraphobia or Agoraphobia Without History of Panic Disorder.
Truancy is common in Conduct Disorder, but anxiety about separation is not responsible for school absences and the child usually stays away from, rather than returns to, the home.
Some cases of school refusal, especially in adolescence, are due to Social Phobia or Mood Disorders rather than separation anxiety.
Unlike the hallucinations in Psychotic Disorders, the unusual perceptual experiences in Separation Anxiety Disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the presence of an attachment figure.
Developmentally appropriate levels of separation anxiety
Clinical judgement must be used in distinguishing developmentally appropriate levels of separation anxiety from the clinically significant concerns about separation seen in Separation Anxiety Disorder.
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- 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 come to them, 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.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
Separation anxiety disorder is distinguished from generalized anxiety disorder in that the anxiety predominantly concerns separation from attachment figures, and if other worries occur, they do not predominate the clinical pictures.
Threats of separation may lead to extreme anxiety and even a panic attack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the possibility of being away from attachment figures and worry about untoward events befalling them, rather than being incapacitated by an unexpected panic attack.
Unlike individuals with agoraphobia, those with separation anxiety disorder are not anxious about being trapped or incapacitated in situations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating symptoms.
School avoidance (truancy) is common in conduct disorder, but anxiety about separation is not responsible for school absences, and the child or adolescent usually stays away from, rather than returns to, the home.
School refusal may be due to social anxiety disorder (social phobia). In such instances, the school avoidance is due to fear of being judged negatively by others rather than to worries about being separated from the attachment figures.
Fear of separation from loved ones is common after traumatic events such as disasters, particularly when periods of separation from loved ones were experienced during the traumatic event. In posttraumatic stress disorder (PTSD), the central symptoms concern intrusions about, and avoidance of, memories associated with the traumatic event itself, whereas in separation anxiety disorder, the worries and avoidance concern the well-being of attachment figures and separation from them.
Individuals will illness anxiety disorder worry about specific illnesses they may have, but the main concern is about the medical diagnosis itself, not about being separated from attachment figures.
Intense yearning or longing for the deceased, intense sorrow and emotional pain, and preoccupation with the deceased or the circumstances of the death are expected responses occurring in bereavement, whereas fear of separation from other attachment figures is central in separation anxiety disorder.
These disorders may be associated with reluctance to leave home, but the main concern is not worry or fear of untoward events befalling attachment figures, but rather low motivation for engaging with the outside world. However, individuals with separation anxiety disorder may become depressed while being separated or in anticipation of separation.
Children and adolescents with separation anxiety disorder may be oppositional in the context of being forced to separate from attachment figures. Oppositional defiant disorder should be considered only when there is persistent oppositional behavior unrelated to the anticipation or occurrence of separation from attachment figures.
Unlike the hallucinations in psychotic disorders, the unusual perceptual experiences that may occur in separation anxiety disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the presence of an attachment figure.
Dependent personality disorder is characterized by an indiscriminate tendency to rely on others, whereas separation anxiety disorder involves concern about the proximity and safety of main attachment figures. Borderline personality disorder is characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to that disorder, whereas they are not central to separation anxiety disorder.