separation anxiety disorder separation anxiety disorder separation anxiety disorder (sad) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment (e.g., a parent, caregiver, significant other, or siblings). separation anxiety is a natural part of the developmental process. it is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. unlike sad (indicated by excessive anxiety), normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem. separation anxiety disorderspecialtypsychiatry according to the american psychiatric association (apa), separation anxiety disorder is an excessive display of fear and distress when faced with situations of separation from the home and/or from a specific attachment figure. the anxiety that is expressed is categorized as being atypical of the expected developmental level and age. the severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation. sad may cause significant negative effects within areas of social and emotional functioning, family life, and physical health of the disordered individual. the duration of this problem must persist for at least four weeks and must present itself before a child is eighteen years of age to be diagnosed as sad in children, but can now be diagnosed in adults with a duration typically lasting six months in adults as specified by the dsm-5. background the origins of separation anxiety disorder stem from attachment theory which has roots in the attachment theories both of sigmund freud and john bowlby. freud's attachment theory, which has similarities to learning theory, proposes that infants have instinctual impulses, and when these impulses go unnoticed, it traumatizes the infant. the infant then learns that when their mother is absent, this will be followed by a distressing lack of gratification, thus making the mother's absence a conditioned stimulus that triggers anxiety in the infant who then expects their needs to be ignored. the result of this association is that the child becomes fearful of all situations that include distance from their caregiver. john bowlby's attachment theory also contributed to the thinking process surrounding separation anxiety disorder. his theory is a framework in which to contextualize the relationships that humans form with one another. bowlby suggests that infants are instinctively motivated to seek proximity with a familiar caregiver, especially when they are alarmed, and they expect that in these moments they will be met with emotional support and protection. he poses that all infants become attached to their caregivers, however, there are individual differences in the way that these attachments develop. there are 4 main attachment styles according to bowlby; secure attachment, anxious-avoidant attachment, disorganized attachment, and anxious-ambivalent attachment. anxious-ambivalent attachment is most relevant here because its description, when an infant feels extreme distress and anxiety when their caregiver is absent and does not feel reassured when they return, is very similar to sad. signs and symptoms academic setting as with other anxiety disorders, children with sad tend to face more obstacles at school than those without anxiety disorders. adjustment and relating school functioning have been found to be much more difficult for anxious children. in some severe forms of sad, children may act disruptively in class or may refuse to attend school altogether. it is estimated that nearly 75% of children with sad exhibit some form of school refusal behavior. there are several possible manifestations of this disorder when the child is introduced into an academic setting. a child with sad may protest profusely upon arrival at school. they might have a hard time saying goodbye to their parents and exhibit behaviors like tightly clinging to the parent in a way that makes it nearly impossible for the parent to detach from them. they might scream and cry but in a way that makes it seem as though they were in pain. the child might scream and cry for an extended period of time after his or her parents are gone (for several minutes to upwards of an hour) and refuse to interact with other children or teachers, rejecting their attention. they might feel an overwhelming need to know where their parents are and that they are okay. this is a serious problem because, as children fall further behind in coursework, it becomes increasingly difficult for them to return to school. short-term problems resulting from academic refusal include poor academic performance or decline in performance, alienation from peers, and conflict within the family. although school refusal behavior is common among children with sad, it is important to note that school refusal behavior is sometimes linked to generalized anxiety disorder or possibly a mood disorder. that being said, a majority of children with separation anxiety disorder have school refusal as a symptom. up to 80% of children who refuse school qualify for a diagnosis of separation anxiety disorder. home setting symptoms for sad might persist even in a familiar and/or comfortable setting for the child, like the home. the child might be afraid to be in a room alone even if they know that their parent is in the next room over. they might fear being alone in the room, or going to sleep in a dark room. problems might present themselves during bedtime, as the child might refuse to go to sleep unless their parent is near and visible. during the day, the child might "shadow" the parent and cling to their side. workplace just how sad affects a child's attendance and participation in school, their avoidance behaviors stay with them as they grow and enter adulthood. recently, "the effects of mental illness on workplace productivity have become a prominent concern on both the national and international fronts". in general, mental illness is a common health problem among working adults, 20% to 30% of adults will suffer from at least one psychiatric disorder. mental illness is linked to decreased productivity, and with individuals diagnosed with sad their levels at which they function decreases dramatically resulting in partial work-days, increase in number of total absences, and "holding back" when it comes to carrying out and completing tasks. cause factors that contribute to the disorder include a combination and interaction of biological, cognitive, environmental, child temperament, and behavioral factors. children are more likely to develop sad if one or both of their parents was diagnosed with a psychological disorder. recent research by daniel schechter and colleagues have pointed to difficulties of mothers who have themselves had early adverse experiences such as maltreatment and disturbed attachments with their own caregivers, who then go on to develop responses to their infants' and toddlers' normative social bids in the service of social referencing, emotion regulation, and joint attention, which responses are linked to these mothers own psychopathology (i.e. maternal post-traumatic stress disorder (ptsd) and depression.) these atypical maternal responses, which have been shown to be associated with separation anxiety, have been related to disturbances in maternal stress physiologic response to mother-toddler separation, as well as lower maternal neural activity in the brain region of the medial prefrontal cortex, when mothers with and without ptsd were shown video excerpts of their own and unfamiliar toddlers during mother-child separation versus free-play. living in a low socioeconomic status (ses) has also been shown to contribute to childhood sad by increasing levels of parental depression. many psychological professionals have suggested that early or traumatic separation from a central caregiver in a child's life can increase the likelihood of them being diagnosed with sad, school phobia, and depressive-spectrum disorders. some children can be more vulnerable to sad due to their temperament, for example, their level of anxiety when placed in new situations. environmental most often, the onset of separation anxiety disorder is caused by a stressful life-event, especially a loss of a loved one or pet, but can also include parental divorce, change of school or neighborhood, natural disasters, or circumstances which forced the individual to be separated from their attachment figure(s). in older individuals, stressful life experiences may include going away to college, moving out for the first time, or becoming a parent. according to the dsm-5, young adults with separation anxiety disorder have different examples of stress, including leaving their parents' home, entering a romantic relationship, and becoming a parent. in some cases, parental overprotectiveness may be associated with separation anxiety disorder. genetic and physiological there may be a genetic predisposition in children with separation anxiety disorder. "separation anxiety disorder in children may be heritable." "heritability was estimated at 73% in a community sample of 6-year-old twins, with higher rates in girls." a child's temperament can also impact the development of sad. timid and shy behaviors may be referred to as "behaviorally inhibited temperaments" in which the child may experience anxiety when they are not familiar with a particular location or person. low levels of child effortful control and self-regulation, the abilities to regulate one’s emotional, sensory, and behavioral responses and impulses, have also been shown to contribute to the development of sad. additionally, higher levels of child negative affect, or tendencies to display negative emotions and remain in such a state, also predict sad. there are also unique genetic traits that may contribute to sad development in adulthood. one study found that negative temperament predicted higher levels of adult separation anxiety. mechanism preliminary evidence shows that heightened activity of the amygdala may be associated with symptoms of separation anxiety disorder. defects in the ventrolateral and dorsomedial areas of the prefrontal cortex are also correlated to anxiety disorders in children. diagnosis separation anxiety occurs in many infants and young children as they are becoming acclimated with their surroundings. this anxiety is viewed as a normal developmental phase between the months of early infancy until age two. separation anxiety is normal in young children, until they age 3–4 years, when children are left in a daycare or preschool, away from their parent or primary caregiver. other sources note that a definite diagnosis of sad should not be presented until after the age of three. some studies have shown that hormonal influences during pregnancy can result in lower cortisol levels later in life, which can later lead to psychological disorders, such as sad. it is also important to note significant life changes experienced by the child either previous to or present at the onset of the disorder. for example, children who emigrated from another country at an early age may have a stronger tendency for developing this disorder, as they have already felt displaced from a location they were starting to become accustomed to. it is not uncommon for them to incessantly cling to their caregiver at first upon arrival to the new location, especially if the child is unfamiliar with the language of their new country. these symptoms may diminish or go away as the child becomes more accustomed to the new surroundings. separation anxiety may be diagnosed as a disorder if the child's anxiety related to separation from the home or attachment figure is deemed excessive; if the level of anxiety surpasses that of the acceptable caliber for the child's developmental level and age; and if the anxiety negatively impacts the child's everyday life. many psychological disorders begin to emerge during childhood. nearly two-thirds of adults with psychological disorder show signs of their disorder earlier in life. however, not all psychological disorders are present before adulthood. in many cases, there are no signs during childhood. behavioral inhibition (bi) plays a large role in many anxiety disorders, sad included. compared to children without it, children with bi demonstrate more signs of fear when experiencing a new stimulus, particularly those that are social in nature. children with bi are at a higher risk for developing a mental disorder, particularly anxiety disorders, than children without bi. to be diagnosed with sad, one must display at least three of the following criteria: recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an