Separation Anxiety Disorder (SAD) is an anxiety disorder defined by excessive and developmentally inappropriate fear experienced in situations where the individual is separated, or anticipates separation, from attachment figures. According to the DSM-5 classification, this disorder is not limited to childhood but can also occur in adulthood. SAD is a clinical condition that significantly impacts social, academic and occupational functioning.

SAD typically begins in childhood, but it can also emerge in adulthood, often persisting undiagnosed from earlier years. Even the expectation of separation from attachment figures may provoke intense fear, sadness, worry and physical symptoms. These symptoms may be triggered not only by actual separation but also by being alone, the possibility of separation, or intrusive thoughts that harm might come to attachment figures.

DSM-5 Diagnostic Criteria for Separation Anxiety Disorder

According to DSM-5, a diagnosis of SAD requires at least three of the following symptoms to persist for a minimum of four weeks in children and adolescents, or six months in adults:

• Intense and recurrent distress during anticipation of or actual separation.
• Persistent and irrational fears that attachment figures may be harmed or experience misfortune.
• Excessive worry about events that could cause separation (for example, being kidnapped, getting lost, becoming ill).
• Resistance to separation or refusal to attend school, work or travel.
• Avoidance of being alone or in settings without attachment figures.
• Nightmares with separation-related themes.
• Physical complaints during separation or in anticipation of separation (headaches, nausea, etc.).

These symptoms must cause clinically significant distress or impairment in functioning and cannot be better explained by another disorder.

Symptoms of Separation Anxiety Disorder

Symptoms of SAD can manifest emotionally, behaviorally and physically. Emotionally, individuals experience intense fear, panic, crying spells and helplessness in response to potential separation. Behaviorally, avoidance patterns such as refusing to attend school, avoiding solitude, and insisting on constant proximity to parents are common. Physical symptoms include headaches, stomachaches, nausea, trembling, insomnia and appetite changes.

In adults, symptoms may include decreased occupational performance, dependency in relationships, intense panic following separation, obsessive thoughts, substance use and comorbid depression.

Etiology of Separation Anxiety Disorder

Multiple factors contribute to the development of SAD, and it is best explained within a biopsychosocial framework:

• Genetic Predisposition: Family studies demonstrate increased prevalence of anxiety disorders among relatives. Twin studies support the heritability of separation anxiety (Hudziak et al., 2004).
• Neurobiological Factors: Dysfunctions involving the amygdala, hippocampus and prefrontal cortex constitute the neurobiological basis of anxiety disorders. Imbalances in serotonin, dopamine and norepinephrine systems are also associated with separation anxiety.
• Attachment Theory: According to Bowlby’s attachment theory, failure to establish secure attachment in early childhood increases the risk of developing separation anxiety. Overprotective or neglectful parental attitudes may contribute to this process.
• Traumatic Experiences: Sudden separations such as parental loss, divorce or hospitalization can provoke intense anxiety. Global crises such as the COVID-19 pandemic have also been identified as risk factors increasing separation anxiety in children and adolescents (Orgilés et al., 2020).

Risk Factors for Separation Anxiety Disorder

Prominent risk factors for SAD include:

• Parents with a history of anxiety disorders or depression.
• Family conflicts, divorce, parental loss.
• Overprotective parenting style.
• Low socioeconomic status.
• Female gender (more common in childhood).
• Early entry into daycare or abrupt change of caregiver.

Diagnosis

Diagnosis of SAD requires a comprehensive clinical evaluation. Both individual and family history must be obtained, and the onset, duration and progression of symptoms must be assessed. In addition to clinical interviews, the following assessment tools may support diagnosis:

• SCARED (Screen for Child Anxiety Related Emotional Disorders)
• ADIS (Anxiety Disorders Interview Schedule)
• CBCL (Child Behavior Checklist)
• Separation Anxiety Avoidance Inventory (SAAI) (used in adults)

Differential diagnosis must include generalized anxiety disorder, specific phobia, panic disorder, post-traumatic stress disorder and depression. Organic causes of physical symptoms should also be evaluated.

Treatment of Separation Anxiety Disorder

Treatment of SAD involves psychoeducation, psychotherapy and, when necessary, pharmacotherapy. Management should be tailored according to age, symptom severity and comorbid conditions.

1. Cognitive Behavioral Therapy (CBT)

CBT is the first-line psychotherapeutic intervention for SAD. Therapy focuses on restructuring dysfunctional thoughts related to separation. Exposure-based techniques are used to gradually help the child adapt to separation. Parental involvement is crucial to enhance treatment effectiveness in children.

2. Play Therapy (for Children)

In young children, separation-related anxieties can be addressed through play, which facilitates emotional expression and therapeutic alliance.

3. Family Therapy and Psychoeducation

Families are guided to adopt supportive rather than overprotective or anxiety-reinforcing responses. Psychoeducation provides both children and parents with knowledge about the disorder, its symptoms and coping strategies.

4. Pharmacotherapy

In moderate to severe cases, pharmacological intervention may be considered in combination with CBT. SSRIs (for example, fluoxetine, sertraline) are considered safe and effective for children and adolescents. Medication must always be supervised by a specialist and combined with psychotherapy.

5. Intervention in Adults

Adult SAD frequently co-occurs with depression, generalized anxiety disorder or personality disorders. Treatment therefore requires a more comprehensive plan, involving individual psychotherapy, group therapy and, when necessary, pharmacological support.

Impact on Daily Life

Separation Anxiety Disorder can severely restrict daily functioning. In children, it leads to school refusal, difficulties with peer relationships and reduced academic achievement. Due to fear of separation, the child may avoid school trips, social activities or being apart from parents, hindering social skill development.

In adults, consequences include dependent relationships, exaggerated reactions to partner separation, workplace absenteeism, fear of travel and inability to tolerate solitude. Over time, SAD may predispose to depression, agoraphobia, panic disorder and substance use. It can significantly reduce quality of life, self-confidence and autonomy.

Separation Anxiety Disorder is not exclusive to childhood but can impair functioning across the lifespan. Early diagnosis, appropriate psychotherapy and, when necessary, pharmacological intervention can substantially improve outcomes. Family collaboration, psychoeducation and developmentally sensitive approaches are key to treatment success. SAD should not be overlooked, and increased public awareness as well as timely access to mental health care are essential.