ICD-116B05	SEPARATION ANXIETY DISORDER Separation anxiety disorder
ICD-10F93.0	Separation anxiety disorder of childhood
DSM-5-TRF93.0	Separation Anxiety Disorder

1. Definition and nosology

Separation anxiety disorder (ICD-11: 6B05; DSM-5-TR: F93.0) — developmentally inappropriate excessive fear and anxiety related to separation from an attachment figure (typically parent) or home. First diagnosable in adults in DSM-5 (limited to childhood in DSM-IV).

2. History

• Bowlby J. (1969–1980) — attachment theory.
• DSM-III (1980) — As a childhood disorder.
• DSM-5 (2013) — age restriction removed; diagnosis possible in adults as well.

3. Epidemiology

• Spread in children: ~4%; in adolescents ~1.6%; in adults ~1.9% (Kessler R.C. NCS-R).
• Sex: relatively higher in females.
• Onset: typical childhood (6–9 years); may recur or persist in adult form.
• Comorbidity: specific phobia, panic, GAD, MDD, school avoidance.

4. Aetiology and pathogenesis

• Heritability ~40%.
• Attachment styles (insecure attachment), parental overprotection.
• History of loss or illness in relatives.
• Stressful events (moving, school change, parental separation).

5. Clinical features

• Excessive worry about harm or loss to the attachment figure.
• Avoidance of leaving home or separating from attachment figure.
• Fear of being alone.
• Persistent reluctance or refusal to sleep away from home or to go to sleep without the attachment figure nearby (own bedroom, unfamiliar house).
• Nightmares about migration or separation.
• Somatic complaints in anticipation of separation (abdominal pain, headache, nausea).
• In children — school avoidance.
• In adults — fear of separation from partner or children, excessive checking behaviors.

6. Diagnosis

6.1 Unified diagnostic criteria

A. ≥ 3 of the following symptoms:

1. Excessive anxiety about separation from the attachment figure or anticipation thereof;
2. Persistent worry about loss or harm to the attachment figure;
3. Fear of an event that would cause separation from the attachment figure;
4. Avoidance of home, school, or work due to fear of separation;
5. Fear of being alone without the attachment figure;
6. Reluctance to go to sleep without the attachment figure nearby;
7. Separation nightmares;
8. Somatic complaints in anticipation of separation.

B. Duration: children/adolescents ≥ 4 weeks; adults ≥ 6 months.

C. Significant distress or functional impairment.

D. Not better explained by another mental disorder.

6.2 Source-specific clarifications

• DSM-5-TR — duration ≥6 months in adults; ≥4 weeks in children.
• ICD-11 — a different duration: “at least several months”; there is no DSM-5-TR split into 4 weeks for children and 6 months for adults, and no separate age qualifier.

6.3 Diagnostic algorithm

1. Clinical interview (also with parent in children).
2. Standardized interview (K-SADS for children, SCID-5 for adults).
3. Scale - SAAS (Separation Anxiety Assessment Scale).
4. Comorbidity screening.

6.4 Differential diagnosis

7. Examination and assessment

• SAAS, K-SADS, MASC (Multidimensional Anxiety Scale for Children).
• Comorbidity (depression, other anxiety).

8. Treatment

1. CBT (Coping Cat, FRIENDS programs for children; standard CBT for adults) — exposure-based, parental involvement critical in children. First-line.
2. SSRIs — in moderate-to-severe cases or when CBT fails; sertraline, fluoxetine (in children).
3. School return programs (school refusal) — graded exposure.
4. Family involvement — parental psychoeducation, avoidance of frequent phone calls/visits (accommodation strengthens symptoms).

Source-specific specifications

• AACAP Practice Parameter (Connolly S.D., Bernstein G.A. 2007) — CBT and SSRIs effective in children.
• NICE — general guidelines for childhood anxiety (CBT first-line).
• Walkup J.T. et al. NEJM 2008 (CAMS — Child/Adolescent Anxiety Multimodal Study) — CBT + sertraline combination superior to monotherapy.

Treatment methods

1. “Coping Cat” program — Kendall (Kendall P.C.) — Manualized CBT for children aged 7–17 years – 16 sessions, psychoeducation + relaxation + exposure + reward system (FEAR plan).
2. FRIENDS Program — Barrett (Barrett P.M.) — In Australia, developed group CBT for child and adolescent anxiety disorders.
3. Stepped School Return — Structured exposure — child gradually returns to school environment; coordination of parent and school staff.
4. Parental Accommodation Reduction — SPACE (Supportive Parenting for Anxious Childhood Emotions — Lebowitz E.) program — modifying parental accommodation of child's anxiety.

9. Prognosis

• Remission in most children with early CBT.
• Without treatment, continuation in adulthood leads to risk of other anxiety disorders and depression.

10. Myths and misconceptions

Myth 1: “Separation anxiety occurs only in childhood”

Evidence: DSM-5 — separation anxiety disorder also diagnosed in adults — prevalence ~1.9%.

Myth 2: “The parent must give in to every demand to ‘calm’ the child”

Evidence: Accommodation strengthens the symptoms; the SPACE program or parent training is recommended.

Myth 3: “Separation anxiety is a result of poor parenting”

Evidence: heritability ~40%; attachment and environment modulator. “Bad upbringing” explanation stigmatizing and incorrect.

Myth 4: “Leaving a child alone to ‘get used to it’ — this harsh approach cures them”

Evidence: “Flooding” or uncontrolled exposure can be traumatic; graded, structured exposure recommended.

Myth 5: “Recovery is only possible with medication”

Evidence: CBT first-line; SSRIs for moderate-severe cases or in combination.

Myth 6: “School refusal is a personality weakness and requires discipline”

Evidence: School avoidance is a clinical anxiety symptom; punishment-based approach exacerbates the disorder.

11. Sources

1. WHO. ICD-11. 6B05 Separation anxiety disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. Connolly S.D., Bernstein G.A. AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry 2007;46(2):267–283.
4. Walkup J.T. et al. CAMS: Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. NEJM 2008;359(26):2753–2766.
5. Kendall P.C. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 1994;62(1):100–110.
6. Lebowitz E.R. et al. Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions. J Am Acad Child Adolesc Psychiatry 2020;59(3):362–372.
7. Barrett P.M., Turner C. Prevention of anxiety symptoms in primary school children. Br J Clin Psychol 2001;40(4):399–410.
8. Kessler R.C., Berglund P., Demler O. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):593–602.