Introduction

Separation anxiety disorder (SAD) affects nearly 4–8% of the children globally, making it one of the most common types of anxiety disorders in childhood with the continuation into adulthood becoming more and more apparent (APA, 2022; Kowalchuk et al., 2022). Nurses are often exposed to children and families that are devastated with fear of being separated but the symptoms are often overlooked as normal developmental changes. In turn, this leads to delays in diagnosis and intervention. This blog discusses the separation anxiety disorder, its presentation, theoretical basis, and evidence-based management. You will discover how to differentiate between typical developmental anxiety and pathology, identify symptoms according to the DSM-5-TR-aligned symptoms, and implement early, family-based interventions. Understanding the disorder can help nurses to support children and caregivers in overcoming the disorder, reducing long-term psychiatric morbidity and ensuring healthy development.

Understanding Separation Anxiety Disorder

Overview of SAD

Normative vs. Pathological Separation Anxiety

SAD is a clinically significant anxiety disorder marked by an excessive and developmentally inappropriate anxiety or fear with regard to separation with attachment figures. Although separation anxiety is a normal development process in early childhood, SAD is different, in terms of severity, length and functional dysfunction. The acute distress in most infants and toddlers when they are separated occurs during the period between 9 and 18 months and is usually resolved when the emotional regulation and object permanence achieve maturity (Tekin & Aydın, 2023. But SAD, in contrast to normal development, continues at age levels inappropriate to it and disrupts the normal everyday activities, such as attending school, interactions with peers, sleep, and family dynamics (APA, 2024; Feriante et al., 2023).

Risk of Chronicity

Though seen as a disorder of childhood, SAD is at present identified throughout the lifespan, with prevalence in adults between 1 % and 2 % (Ekici et al., 2023). SAD can go without detection and diagnosis, with its progression leading to challenges during adulthood. The disorder increases the risk of the development of panic disorder, generalized anxiety disorder and depression later in life without interventions (APA, 2022). Prevention and long-term promotion of mental health should therefore be based on early recognition and nurse-led education.

Relevance to Patients and Nursing Practice

Nurses are often the initial contact during primary care, school health, pediatrics and mental health care visits. The patients tend to have a constant fear of something bad happening to their attachment figures, shunning of circumstances that cause separation, anxiety about separation, or symptoms of somatic anxiety. According to Feriante et al. (2023), in the assessment of SAD, some of the areas that can be taken into consideration by the nurses in addition to the diagnostic criteria include:

• Recurrent school refusal
• Recurrent and unexplainable physical complaints
• Sleep disturbances requiring caregiver attention and proximity
• Heightened parental anxiety and accommodation

Failing to recognize such subtle behaviors potentiates academic failure, social withdrawal, caregiver burnout, and progression to other anxiety or depressive disorders(Creswell et al., 2024).

Signs and Symptoms

Separation anxiety disorder can manifest through emotional, behavioral, and physical signs (Patel & Bryant, 2021).

Emotional Signs

Some of the common emotional signs of SAD include the following:

• Repeated and excessive distress, phobia, panic and anxious expression
• Hysteria and extreme emotional responses toward parental separations
• Rumination over fear-based beliefs concerning abandonment, the departure of caregivers without any reunion, or something negative happening to them including illness, injuries, calamities, or death
• Negative self-perceptions regarding their safety and well-being being in threat without their caregiver; children can ruminate on the fear of being kidnapped, injured or lost when they are not with their parents
• Adults could express emotional symptoms such as excessive reassurance-seeking, fear of abandonment, and distress when separated from partners.

Behavioral Signs

Individuals may exhibit a range of behavioral signs, including, but not limited to the following:

• Clinginess to attachment figures that inhibits a child from exploring social environments without the immediate presence of the caregiver. A child will often enjoy playing with the caregivers closely and gets upset whenever the caregiver is not around. During transitions, the child might hide or attach himself or herself to caregivers as a plea against their departure
• Recurrent tantrums and distress with emotional dysregulation
• Avoidant behaviors such as refusal to leave home or to transition into daycare, school, or play dates due to fears of being away from caregivers
• Regression to behaviors inconsistent with the developmental stage, for example, wetting the bed and sucking thumbs among others
• When separated, patients tend to portray safety-seeking behaviors such as calling or texting the attachment figure frequently

Physical Signs

            Some of the common somatic symptoms include:

• Abdominal pain
• Headaches
• Fatigue or dizziness
• Nausea and/or vomiting

The symptoms commonly occur in anticipation of separation and often resolve in the presence of the attachment figure (Kowalchuk et al., 2022). Mental-health screening should be done in response to repeated medical assessments where organic causes are not found.

Theoretical Perspectives of Separation Anxiety Disorder

Attachment Theory

Attachment theory offers the primary theoretical understanding of SAD. Secure attachment develops when caregivers respond consistently and sensitively to a child’s needs. Insecure attachment, particularly anxious or ambivalent patterns, has been strongly associated with separation anxiety (Diamond & Keefe, 2024). Anxiously attached children might believe the caregivers to be inconsistently available, which increases the levels of fear of separation. Nursing interventions that encourage caregiver responsiveness and emotional sensitivity are thus formative.

Developmental Context

            The presentation of the symptoms may differ significantly depending on the attachment behaviors across the developmental stages (Kurt & Taşdemir, 2025; Tng et al., 2025).

• Infants: Separation distress is normative and adaptive
• Toddlers: Increasing autonomy reduces anxiety with reassurance
• Preschool children: Persistence of intense anxiety becomes concerning
• School-Age Children: SAD often presents as school refusal
• Adolescents: Symptoms may shift toward social withdrawal
• Adults: Anxiety centers on romantic or caregiving relationships

Understanding the trajectory across developmental stages can enable nurses to differentiate between normal anxiety and pathological anxiety.

Factors that Contribute to Separation Anxiety Disorder

• Family history or genetic predisposition
• Parental overprotection
• Insecure attachment patterns during early childhood
• History of traumatic separation experiences
• Family stressors such as relocation, divorce, illness, or death
• Dysregulation of neurobiological circuits
• Temperamental inhibition

Managing Separation Anxiety Disorder

The Importance of Early Intervention

Early diagnosis and treatment are critical to healthy child development. The existing clinical guidelines emphasize stepped-care management depending on severity following diagnosis (Olsson et al., 2025). Delays in identifying and treating SAD can lead to chronicity and comorbidity. Age-appropriate therapeutic approaches are required help children and their caregivers learn to recognize patterns and triggers, process emotions, learn to cope with fear-based reactions, and develop resilience.

Psychotherapy “Talk Therapy”

Cognitive behavioral therapy (CBT) is considered the gold-standard therapy. CBT helps children to identify maladaptive thoughts, learn coping mechanisms and step by step overcome feared separations. Parent-based interventions decrease accommodation behaviors and increase the overall treatment effectiveness (Preś et al., 2024).

Pharmacotherapy

Selective serotonin reuptake inhibitors (SSRI) can be considered in case of CBT failure or unavailability, or the symptoms are severe and disabling. Nevertheless, SSRIs are contraindicated in children younger than six years old and should be closely monitored with the side effects, such as gastrointestinal discomfort, sedation, behavioral stimulation, and withdrawal symptoms (Arnardóttir & Skarphedinsson, 2023). Psychotherapy must never be substituted by medication.

Helping Parents and Caregivers to Cope with SAD

Desensitization and Gradual Exposure

Parents are an important factor influencing gradual, planned separations where tolerance and confidence are developed. Exposure needs to be predictable, time based and positively reinforced (Teunisse et al., 2023). Separations can be systematically prolonged by the caregivers, as the comfort of their child is enhanced with practice. As the child gets used to the reaction and the fear induced by the separation reduces, they become desensitized to it and more independent. Nurses and play therapists can guide caregivers to use the imaginal exposure technique involving role-playing to rehearse the scenarios that cause anxiety to the child before exposure to separation. For children, practicing such situations with toys can enable inhibitory learning and habituation, decreasing anxiety with repeated practice.

Predictability and Routines

Predictable routines can foster emotional stability. Nurses should educate caregivers to use calm and brief goodbyes, while avoiding excessive reassurances that often augment anxiety. Moreover, they should encourage parents or caregivers on how to establish consistent schedules, and track routines using visual charts, which could create consistency and allow children to adjust smoothly to the conditions of separation (Jreisat, 2023).

Transitions and Emotion Regulation Skills

Resilience can be improved by teaching children emotion-regulation techniques, including deep breathing, mindfulness, problem-solving, and meditation (Monsillion et al., 2023; Morales-Rodriguez & Morales-Rodriguez, 2024). Nurses can reinforce these skills during clinical encounters and after educating parents on their importance. They should also encourage parents not to have long transition periods that may make the children ambivalent.

Conclusion

SAD is a debilitating and often-overlooked anxiety disorder that occurs especially in children and, at times, adults. Recognizing the disorder early is critical to initiating age-appropriate interventions. CBT is widely recommended, with active parental participation augmenting management at home. SSRIs could be considered in case psychotherapy fails, but this should involve significant caution. Nurses are well-positioned to offer evidence-based and family-centered assessments and interventions, including educating parents or caregivers on coping strategies that could be helpful. Action is the second step: it is necessary to make the routine check of anxiety screening part of practice, teach caregivers about healthy separation techniques, and promote the use of mental health services early to ensure healthy child development.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders DSM-5 – Test revision (5th ed.). Washington DC: American Psychiatric Association.

Arnardóttir, A., & Skarphedinsson, G. (2023). Comparative effectiveness of cognitive behavioral treatment, serotonin, and serotonin noradrenaline reuptake inhibitors for anxiety in children and adolescents: a network meta-analysis. Nordic Journal of Psychiatry, 77(2), 118-126. https://doi.org/10.1080/08039488.2022.2069858

Creswell, C., Waite, P., & Cooper, P. J. (2024). Assessment and management of anxiety disorders in children and adolescents. Archives of disease in childhood, 99(7), 674–678. https://doi.org/10.1136/archdischild-2023-303768

Diamond, D., & Keefe, J. R. (2024). Separation anxiety: The core of attachment and separation-individuation. The Psychoanalytic Study of the Child, 77(1), 251-274. https://doi.org/10.1080/00797308.2023.2284588

Ekici, F., Karaoğlan, G., Kandeğer, A., Demir, L. S., & Güler, Ö. (2023). Exploring overlooked anxiety disorders: A study on the prevalence of adult separation anxiety disorder and specific phobia in the general population. Genel Tıp Dergisi, 33(6), 796-805. https://doi.org/10.54005/geneltip.1392240

Feriante, J., Torrico, T. J., & Bernstein, B. (2023). Separation Anxiety Disorder. In StatPearls. StatPearls Publishing.

Jreisat, S. (2023). Separation Anxiety among Kindergarten Children and its Association with Parental Socialization. Health Psychology Research, 11, 75363. https://doi.org/10.52965/001c.75363

Kowalchuk, A., Gonzalez, S. J., & Zoorob, R. J. (2022). Anxiety disorders in children and adolescents. American family physician, 106(6), 657-664. https://www.aafp.org/pubs/afp/issues/2022/1200/anxiety-disorders-children-adolescents.html

Kurt, M., & Taşdemir, A. (2025). Adult Separation Anxiety Disorder in Substance Use Disorder: The Role of Trauma and Attachment Styles in Mediating and Moderating Mechanisms. Substance Use & Misuse, 1-9. https://doi.org/10.1080/10826084.2025.2601320

Monsillion, J., Zebdi, R., & Romo-Desprez, L. (2023). School Mindfulness-Based Interventions for Youth, and Considerations for Anxiety, Depression, and a Positive School Climate—A Systematic Literature Review. Children, 10(5), 861. https://doi.org/10.3390/children10050861

Morales-Rodríguez, A. M., & Morales-Rodríguez, F. M. (2024). Effectiveness of a Mindfulness-Based Intervention Program to Improve Communication and Stress Coping Skills in University Students. European Journal of Investigation in Health, Psychology and Education, 14(7), 1927. https://doi.org/10.3390/ejihpe14070128

Olsson, E., Andrén, P., Claesdotter-Knutsson, E., Dellgran, K., Castro, O. C., Möttus, A., Mataix-Cols, D., Gusic, S., Perrin, S., Serlachius, E., & Cervin, M. (2025). Stepped Care Versus Stratified Care for Youth with Anxiety Disorders: a Pilot Randomized Controlled Trial. Child Psychiatry & Human Development, 1-14.

Patel, A. K., & Bryant, B. (2021). Separation anxiety disorder. Jama, 326(18), 1880-1880. https://doi.org/10.1001/jama.2021.17269

Preś, J. E., Świątkowska, K., & Kołakowski, A. (2024). Cognitive behavioral therapy for the treatment of separation anxiety disorder in children – a research review and case study. Psychiatria polska, 58(5), 761–771. https://doi.org/10.12740/PP/175718

Tekin, I., & Aydın, S. (2023). School refusal and anxiety among children and adolescents: A systematic scoping review. New Directions for Child and Adolescent Development, 2022(185-186), 43-65. https://doi.org/10.1002/cad.20484

Teunisse, A. K., Pembroke, L., Sy, M., Rapee, R. M., Wuthrich, V. M., Creswell, C., & Hudson, J. L. (2023). A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people. JCPP Advances, 2(2), e12080. https://doi.org/10.1002/jcv2.12080

Tng, G. Y. Q., Law, E. C., Chen, H. Y., Nadarajan, R., Eriksson, J. G., Chong, Y. S., Tiemeier, H., & Setoh, P. (2025). Developmental Trajectories of Anxiety Subtypes from Childhood to Early Adolescence: the Role of Parenting Practices and Maternal Distress. Research on child and adolescent psychopathology, 53(11), 1699–1712. https://doi.org/10.1007/s10802-025-01364-4