separation anxiety

It is normal for toddlers and preschool children to show a degree of anxiety over real or threatened separation from people to whom they are attached. Separation anxiety disorder should be diagnosed only when fear over separation constitutes the focus of the anxiety and when such anxiety arises during the early years. It is differentiated from normal separation anxiety when it is of such severity that is statistically unusual (including an abnormal persistence beyond the usual age period) and when it is associated with significant problems in social functioning. In addition, the diagnosis requires that there should be no generalized disturbance of personality development of functioning; if such a disturbance is present, a code from F40-F49 should be considered. Separation anxiety that arises at a developmentally inappropriate age (such as during adolescence) should not be coded here unless it constitutes an abnormal continuation of developmentally appropriate separation anxiety.


Diagnostic guidelines >

The key diagnostic feature is a focused excessive anxiety concerning separation from those individuals to whom the child is attached (usually parents or other family members), that is not merely part of a generalized anxiety about multiple situations. The anxiety may take the form of:

(a) an unrealistic, preoccupying worry about possible harm befalling major attachment figures or a fear that they will leave and not return;
(b) an unrealistic, preoccupying worry that some untoward event, such as the child being lost, kidnapped, admitted to hospital, or killed, will separate him or her from a major attachment figure;
(c) persistent reluctance or refusal to go to school because of fear about separation (rather than for other reasons such as fear about events at school);
(d) persistent reluctance or refusal to go to sleep without being near or next to a major attachment figure;
(e) persistent inappropriate fear of being alone, or otherwise without the major attachment figure, at home during the day;
(f) repeated nightmares about separation;
(g) repeated occurrence of physical symptoms (nausea, stomachache, headache, vomiting, etc.) on occasions that involve separation from a major attachment figure, such as leaving home to go to school;
(h) excessive, recurrent distress (as shown by anxiety, crying, tantrums, misery, apathy, or social withdrawal) in anticipation of, during, or immediately following separation from a major attachment figure.

Many situations that involve separation also involve other potential stressors or sources of anxiety. The diagnosis rests on the demonstration that the common element giving rise to anxiety in the various situations is the circumstance of separation from a major attachment figure. This arises most commonly, perhaps, in relation to school refusal (or "phobia"). Often, this does represent separation anxiety but sometimes (especially in adolescence) it does not. School refusal arising for the first time in adolescence should not be coded here unless it is primarily a function of separation anxiety, and that anxiety was first evident to an abnormal degree during the preschool years. Unless those criteria are met, the syndrome should be coded in one of the other categories in F93 or under F40-F48.

* mood [affective] disorders (F30-F39)
* neurotic disorders (F40-F48)
* phobic anxiety disorder of childhood (F93.1)
* social anxiety disorder of childhood (F93.2)