Separation anxiety disorder

Separation anxiety cases often arrive as school refusal or a clinging child, but the diagnosis applies across the lifespan; the exam tests whether the fear is developmentally excessive and centered on separation from attachment figures.

Criteria at exam depth. Fear or anxiety about separation from those to whom the client is attached, developmentally inappropriate and excessive, shown by three or more of: recurrent distress when anticipating or experiencing separation from home or attachment figures; persistent worry about losing attachment figures or harm coming to them (illness, accidents, death); worry that an untoward event (getting lost, being kidnapped) will cause separation; reluctance or refusal to go out, to school or work because of separation fear; fear of being alone without attachment figures; reluctance to sleep away from home or without being near an attachment figure; nightmares about separation; and physical complaints (headaches, stomachaches, nausea) when separation occurs or is anticipated. Duration is at least four weeks in children and adolescents and typically six months or more in adults. It causes significant impairment and is not better explained by another disorder.

Hinge differentials.

• Generalized anxiety disorder: worry spans many domains, not specifically separation.
• Trauma- and stressor-related reactions (PTSD, adjustment disorder): separation fear after a traumatic event or major loss (disaster, death, deployment) may be better explained by the trauma reaction.
• Agoraphobia: fear of situations where escape or help is unavailable, not fear of being apart from attachment figures.
• Social anxiety disorder: school avoidance driven by fear of peers' judgment.
• Depression: school refusal from anhedonia and low energy.
• Normal developmental separation anxiety: expected in toddlers and young children; transient and not impairing.
• Conduct problems or truancy: absence without fear, often hidden from parents.

On the NCMHCE. The counselor identifies what keeps the child out of school (fear of harm to the parent, not dislike of school) and gathers collateral from parents and teachers. Rule out medical causes of somatic complaints and screen for recent loss, family stressors, trauma and parental anxiety, which often reinforce avoidance through accommodation. First-line treatment is CBT with graded exposure to separation, paired with parent involvement: coaching parents to reduce accommodation, use brief predictable goodbyes and reinforce brave behavior. Coordinate a gradual school return plan with school staff. In adults, explore attachment history and relationship dependency. Consider cultural norms about family closeness, co-sleeping and independence before judging separation fear excessive.

Clinical Pearl: Three of eight separation-focused symptoms; at least four weeks in youth, typically six months in adults. School refusal driven by fear of harm to a parent points here, and treatment means graded exposure plus parents reducing accommodation.