Separation Anxiety Disorder: Symptoms, Causes and Treatment

Is Your Child Struggling to Separate from You?

Tears at the school gate every morning, inability to sleep alone at night, constant complaints of "stomach ache"... This picture is familiar to many families in Ankara. Watching your child go through such difficulty is exhausting for both of you. You may be asking yourself: "Am I being overprotective?" or "Is this normal — will it pass?"

Separation anxiety disorder is one of the most common anxiety disorders in childhood and, with the right approach, it can largely be overcome. At the Ankara clinic of Assoc. Prof. Dr. Mehtap Eroglu, science-based, effective treatment programmes are applied for children and families experiencing this problem. This article has been prepared to help you understand the topic in depth and take the right steps.

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Key Points

- Separation anxiety disorder is a genuine psychiatric diagnosis seen in approximately **4-5% of children** and leads to school refusal and significant somatic symptoms.
- It differs from **normal developmental separation anxiety**; it severely impairs functioning and lasts more than 4 weeks.
- **Cognitive Behavioural Therapy (CBT)** and **gradual exposure** techniques are the most effective treatments supported by scientific evidence.
- Parents' behaviour plays a **decisive role** in the treatment process; overprotection can reinforce anxiety.
- Assoc. Prof. Dr. Mehtap Eroglu provides expert support in Ankara for the diagnosis and treatment of separation anxiety disorder and many other childhood and adolescent psychiatric conditions.

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What Is Separation Anxiety? The Difference from Normal Anxiety

Normal Separation Anxiety in Development

Separation anxiety is actually a natural part of a healthy attachment relationship. Babies start reacting to unfamiliar faces at around **6-8 months** and cry when separated from parents. This is a sign of cognitive development: they have now grasped object permanence, meaning when a parent disappears from sight, they think "they have really gone."

**Normal separation anxiety boundaries by age:**

- **6-12 months:** Stranger anxiety and separation reactions begin; completely normal.
- **12-24 months:** Reaches peak. Intense crying during parental separations is seen.
- **2-3 years:** Gradually decreases; the child starts to understand that you will return.
- **3-5 years:** Decreases significantly; adaptation to pre-school is usually achieved.
- **5 years and above:** Separation anxiety should have reduced markedly.

Transition to Separation Anxiety Disorder: When to Worry?

When anxiety goes far beyond developmental expectations, impairs functioning, and persists for at least **4 weeks**, we can speak of a disorder. According to the clinical assessments of Assoc. Prof. Dr. Mehtap Eroglu at her Ankara clinic, the following signals require attention:

- A school-age child (over 6) consistently refusing to go to school
- Inability to tolerate even a parent briefly stepping into another room
- Intense, uncontrollable worries about separation filling daily life
- Recurrent physical complaints (nausea, headache, stomach ache) with no organic cause found on examination
- Severe disruption to sleep patterns

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Symptoms and Diagnostic Criteria

DSM-5 Diagnostic Criteria

According to the American Psychiatric Association's DSM-5 diagnostic manual, a diagnosis of separation anxiety disorder requires at least **three of the following symptoms** and they must persist for **more than 4 weeks**:

1. **Excessive distress when anticipating or experiencing separation:** Intense distress when separating from home or attachment figures.
2. **Persistent excessive worry:** Intense concerns about harm coming to attachment figures or about them leaving.
3. **Fear of loss or abduction:** Worry about being separated from attachment figures through accident, illness or death.
4. **Avoidance of being alone:** Consistent avoidance of being at home or elsewhere without attachment figures nearby.
5. **Sleep problems:** Refusal to sleep or leave the bedroom without attachment figures; separation themes frequently appearing in nightmares.
6. **Somatic symptoms:** Recurrent headaches, stomach aches, nausea or vomiting when separation occurs or is anticipated.
7. **Avoidance of school or social settings:** Refusal to go to school, camp or a friend's house.
8. **Inability to sleep alone:** Insistence on sharing a parent's bed; repeatedly getting up at night.

The Importance of Somatic Symptoms

A comment we hear very frequently from Ankara families is: "We took them to the doctor and they found nothing — they said it was all nerves." This is precisely where psychiatric evaluation comes in. Assoc. Prof. Dr. Mehtap Eroglu identifies through detailed clinical interviews that the child's physical complaints represent the somatisation of anxiety and informs families accordingly.

Stomach ache is the most common somatic symptom in separation anxiety disorder; it peaks in the mornings before school. Headache increases especially on school days or when a parent is about to leave. Nausea and vomiting may appear before or during separation. Fatigue and weakness are the body's response to chronic anxiety.

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Causes: Biological and Environmental Factors

Biological Predisposition

Anxiety disorders develop on a biological foundation. Research shows that separation anxiety disorder carries a **genetic transmission** component. Children whose mothers or fathers have a history of anxiety disorder, panic disorder or depression show a markedly higher incidence of separation anxiety disorder.

**From a neuroscientific perspective:**
- The **amygdala** (the brain's danger-detection centre) shows excessive reactivity.
- The **prefrontal cortex** (the centre of rational thought and control) fails to adequately inhibit anxiety.
- Imbalances in the **serotonin and norepinephrine** systems raise anxiety levels.
- Children born with a "behaviourally inhibited" or highly sensitive temperament are biologically more vulnerable.

Environmental and Psychological Factors

**Attachment style:** An anxious attachment pattern predisposes a child to separation anxiety disorder. Inconsistent or unpredictable parental responses create a chronic sense of uncertainty in the child.

**Overprotective parenting:** This leads the child to perceive non-dangerous situations as dangerous. Parental anxiety can be "contagious." At the Ankara clinic, Assoc. Prof. Dr. Mehtap Eroglu explains this carefully to families.

**Stressful life events:** Loss of a loved one (death, divorce, relocation), a serious illness or accident, or a change of school can act as triggers.

**School bullying and social rejection:** Negative experiences related to the school environment can evolve into a separation anxiety intertwined with school refusal.

**Post-pandemic impact:** The incidence of separation anxiety disorder increased markedly among children who spent long periods at home during the COVID-19 pandemic. This picture led to a significant rise in clinic referrals across Ankara and throughout Turkey in the post-pandemic period.

The Relationship Between Separation Anxiety and School Refusal

School refusal is one of the most concrete manifestations of separation anxiety disorder. However, not every case of school refusal stems from separation anxiety; social anxiety, specific phobia, depression or bullying can also lead to school refusal. Differential diagnosis is therefore of great importance in the clinical practice of Assoc. Prof. Dr. Mehtap Eroglu in Ankara.

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How Separation Anxiety Disorder Presents at Different Ages

An important observation from my clinical practice in Ankara is that separation anxiety disorder manifests differently across age groups. As Assoc. Prof. Dr. Mehtap Eroglu, recognising age-specific symptoms is the first step in creating the right intervention plan.

**Preschool period (3-5 years):** During this period, children strongly refuse to physically separate from parents. At the moment of being left at nursery or kindergarten, they display intense crying, clinging and physical resistance. Families in Ankara frequently interpret these reactions as "shyness" or "lack of habit"; however, if symptoms persist for weeks, professional evaluation is necessary.

**Primary school period (6-10 years):** School refusal becomes most prominent during this period. The child presents somatic complaints such as stomach ache and headache in the mornings; these typically disappear on weekends and holidays. Assoc. Prof. Dr. Mehtap Eroglu in Ankara recommends careful evaluation of somatic symptoms in this age group and psychiatric assessment combined with paediatric examination when needed. Night terrors, insistence on sleeping in the parent's bed, and avoidance of being alone also become prominent during this period.

**Adolescence (11-17 years):** In adolescents, separation anxiety disorder can present in more covert forms. Rather than directly "being unable to separate from mother," it manifests as school refusal, reluctance to leave home, not participating in peer activities, or constantly texting to check where parents are. In my adolescent patients in Ankara, I frequently observe that this presentation can be confused with social anxiety or depression. As Assoc. Prof. Dr. Mehtap Eroglu, I emphasise the importance of differential diagnosis in this age group.

Comorbidities: Which Disorders May Co-Occur?

Separation anxiety disorder rarely presents in isolation. Conditions that frequently co-occur in my clinical experience in Ankara include:

- **Generalised anxiety disorder:** Approximately 30-40% of children with separation anxiety also have generalised anxiety disorder. The child worries excessively not only about separation but about many topics.
- **Social anxiety disorder:** Avoidance of peer interaction, particularly in the school setting, can become intertwined with separation anxiety.
- **Specific phobias:** Specific fears such as fear of the dark or animal phobia frequently accompany the condition.
- **ADHD:** When attention deficit hyperactivity disorder co-occurs with anxiety disorders, it complicates the diagnosis and treatment plan.
- **Depression:** Long-standing separation anxiety disorder can predispose to depressive symptoms, particularly in adolescents.

The comprehensive evaluation conducted at the Ankara clinic of Assoc. Prof. Dr. Mehtap Eroglu ensures that these comorbidities are identified and each one is incorporated into the treatment plan. A holistic approach significantly increases treatment success.

Treatment Approaches

Cognitive Behavioural Therapy (CBT)

The method with the **strongest scientific evidence** for treating separation anxiety disorder is Cognitive Behavioural Therapy. The CBT programme applied by the Assoc. Prof. Dr. Mehtap Eroglu team in Ankara includes the following components:

**1. Psychoeducation:** The child and family are taught what anxiety is, how it works, and why it feels so powerful. The "anxiety alarm system" metaphor greatly helps children understand the concept.

**2. Somatic Awareness and Relaxation Techniques:** The child learns to recognise anxiety signals in the body (racing heart, stomach tension, shortness of breath). Deep abdominal breathing and muscle relaxation exercises are incorporated into the daily routine.

**3. Cognitive Restructuring:** Faulty and catastrophising thought patterns such as "something might happen to Mum" or "something bad will happen if I go to school" are questioned and replaced with realistic thoughts.

**4. Gradual Exposure:** An anxiety hierarchy is constructed: a list ranked from least to most anxiety-provoking. The child is progressively exposed to these situations. Each successful step teaches that the anticipated catastrophe does not actually occur.

An example anxiety hierarchy:
- Mum is making tea in another room (Step 1)
- Mum goes to the neighbour's for 10 minutes (Step 2)
- Child stays alone with a babysitter for 1 hour (Step 3)
- First day at school for 2 hours (Step 4)
- Full school day (Step 5)

**5. Reward System:** Brave behaviours are reinforced concretely and consistently. This strengthens the child's motivation to act despite anxiety.

Medication

In moderate-to-severe cases or when CBT alone does not yield a sufficient response, medication may be considered. In the clinical practice of Assoc. Prof. Dr. Mehtap Eroglu in Ankara, the first choice is **selective serotonin reuptake inhibitors (SSRIs)** (for example sertraline or fluoxetine). These medications have been found safe and effective for childhood anxiety disorders.

Medication is never used in isolation; it is always combined with CBT and parents are informed in detail about the medication.

Family Therapy and Parent Guidance

Family dynamics play a critical role in the treatment of separation anxiety disorder. The treatment protocol of Assoc. Prof. Dr. Mehtap Eroglu in Ankara always includes parent guidance covering: management of the parent's own anxiety; reduction of behaviours that reinforce the child's anxiety; creating a consistent and predictable safe environment; and coordinated work with the school.

School-Based Interventions

Collaboration with school counsellors in Ankara significantly accelerates the treatment process. Assoc. Prof. Dr. Mehtap Eroglu communicates with the school when necessary and conveys the school adaptation plan to families.

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A Roadmap for Parents

What to Do

**Name their emotions, do not minimise them:** "I know, it feels a bit sad. But you are safe and I will be here at 3 o'clock." This approach validates the child's feeling and provides reassurance.

**Establish a consistent farewell ritual before separations:** A short, predictable farewell ritual such as "a kiss, a hug and a wave" strengthens the child's sense of control.

**Avoid excessive reassurance-giving:** Do not enter long reassurance loops like "Don't worry, nothing will absolutely happen." While this may help in the short term, it reinforces anxiety in the long term.

**Encourage, do not force:** Convey the message "You can do this, I believe in you." However, avoid phrases like "Don't be a coward, big children don't cry."

**Set gradual steps:** Follow the anxiety hierarchy developed together with the therapist.

What Not to Do

- Constantly cancelling your plans because of the child's anxiety
- Very long and sorrowful goodbyes on school mornings
- Completely avoiding situations that cause anxiety
- Overdramatising the child's fears
- Making negative comparisons with other parents or children
- Showing your own anxiety to the child ("I worry so much about you too")

Techniques You Can Apply at Home

**Anxiety thermometer:** Teach the child to rate their anxiety on a scale of 0-10. This makes an abstract feeling concrete and facilitates communication.

**Worry box:** Ask the child to write worries on paper and put them in a box. "You've left your worries in the box — now you can play freely."

**Courage journal:** Note a small moment of bravery by the child each day. Read through it together at weekends.

**Breathing exercise — "Balloon breath":** Teach the child to breathe deeply as if inflating a balloon in the tummy. Practise for 5 minutes each morning.

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Professional Support with Assoc. Prof. Dr. Mehtap Eroglu

For comprehensive assessment and treatment of separation anxiety disorder in Ankara, you can consult Assoc. Prof. Dr. Mehtap Eroglu, who specialises in child and adolescent psychiatry and serves a wide patient population in Ankara.

Assessment Process

At the first appointment with Assoc. Prof. Dr. Mehtap Eroglu the following takes place:

**1. Comprehensive clinical assessment:** Separate interviews are conducted with the child and parents. The duration, intensity and impact of symptoms on functioning are examined in detail.

**2. Differential diagnosis:** The distinction between separation anxiety disorder and social anxiety, generalised anxiety disorder, school phobia or depression is clarified.

**3. Assessment of family dynamics:** Parents' anxiety levels, intra-family communication patterns and styles of protectiveness are addressed.

**4. Treatment plan:** A treatment programme tailored to the child's age, severity of symptoms and family dynamics is devised.

Services offered at the Ankara clinic of Assoc. Prof. Dr. Mehtap Eroglu include: individual CBT sessions (with the child); parent guidance sessions; family therapy; medication management when required; and coordination with the school.

Appointment and Contact

To make an assessment appointment with Assoc. Prof. Dr. Mehtap Eroglu in Ankara, you can fill in the contact form on our website or reach us via our WhatsApp line. Early referral makes the treatment process both shorter and more effective.

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Conclusion

Separation anxiety disorder is a condition that can largely be overcome with correct diagnosis and treatment. The tearful school gate scene your child experiences every morning is not a reflection of weakness or spoiledness — it is a cry for help from an overactive anxiety system.

In Ankara, Assoc. Prof. Dr. Mehtap Eroglu accompanies families going through this difficult process with a science-based, warm and supportive approach. This holistic programme, combining CBT, parent guidance and medication support when needed, strengthens children's coping skills and helps them — together with their families — return to a healthy daily routine.

If you observe these symptoms in your child, do not wait. Consulting the Ankara clinic of Assoc. Prof. Dr. Mehtap Eroglu for a professional assessment will significantly improve the quality of life of both your child and your entire family.