What is the treatment for separation anxiety?

Treatment for Separation Anxiety

Cognitive-behavioral therapy (CBT) should be offered as the first-line treatment for separation anxiety in children and adolescents aged 6-18 years. 1

First-Line Treatment: Cognitive-Behavioral Therapy

• CBT has demonstrated strong efficacy for separation anxiety with moderate strength of evidence for improving anxiety symptoms (based on child, parent, and clinician reports), global functioning, and treatment response 1
• CBT treatment for separation anxiety typically includes:
  • Psychoeducation about anxiety for both children and parents 1
  • Recognition and reframing of irrational beliefs about separation situations 2, 3
  • Development of coping strategies 2
  • Exposure therapy (gradual exposure to separation situations) 3
• Family involvement is crucial in CBT for separation anxiety, with parent training being an essential component of effective treatment 2, 3
• Studies show that 76-91% of children with separation anxiety show significant improvement after disorder-specific CBT treatment 2

Pharmacological Treatment Options

For cases not responding to CBT or with severe symptoms:

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

   • SSRIs are recommended as the first-line medication option for children and adolescents with separation anxiety disorder 1, 4
   • Start with a low dose and slowly titrate upward to minimize side effects 1
   • Monitor for side effects, particularly during initiation and dose adjustments 1
   • Allow 4-6 weeks at therapeutic dose to assess response 4

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

   • SNRIs can be offered as an alternative medication option for children 6-18 years old with separation anxiety 1
   • SNRIs have shown high strength of evidence for improving clinician-reported anxiety symptoms 1
   • Duloxetine is the only SNRI with FDA indication for anxiety (generalized anxiety) in children 7 years and older 1
   • Be aware that SNRIs may cause increased fatigue/somnolence compared to placebo 1

Combination Treatment Approach

• For moderate to severe cases, combination treatment (CBT plus an SSRI) may be offered preferentially over monotherapy 1
• The Child-Adolescent Anxiety Multimodal Study (CAMS) showed that combination treatment was superior to either CBT or medication alone for treatment response and remission 1
• Initial response to treatment is a strong predictor of long-term outcomes, with combination treatment showing significantly superior initial response 1

Special Considerations

• Parents who themselves struggle with anxiety may benefit from additional psychoeducation and support; a referral for parental treatment may be appropriate 1
• For treatment-resistant cases, consider:
  • Switching between different SSRIs 4
  • Trying an SNRI if SSRIs are ineffective 1
  • Attachment-focused psychodynamic therapy approaches for treatment non-responders 5
• Provide clear, simple instructions to improve treatment adherence, especially when individual therapy from a behavior expert is not available 6

Treatment Pitfalls to Avoid

• Avoid punishment as it may worsen separation anxiety 6
• Don't overlook the importance of parental involvement in treatment; family-based approaches are more effective than child-only interventions 3
• Be aware that separation anxiety is prevalent among non-responders to standard anxiety treatments and may require specific targeted interventions 5
• Recognize that untreated separation anxiety can lead to significant impairments in social, educational, and health outcomes extending from childhood into adulthood 1