Separation anxiety disorder (SAD) in childhood is the child’s disproportionate and maladaptive anxiety when they are separated from their main caregivers, usually the parents, or when they anticipate separation. Anxiety manifests in the form of excessive concern for the well-being and health of the attachment figure or the child themselves (e.g., that the parents might suffer an accident); associated discomfort (e.g., stomachache and nausea at school); and opposition to separation (e.g., protests to prevent parents from going out at night by leaving them with a babysitter) (American Psychiatric Association, 2013).

It is estimated that up to 12% of children are diagnosed with an anxiety disorder (Essau et al., 2018), with SAD being the most prevalent one under 12 years of age (American Psychiatric Association, 2013). Along with several types of specific phobia, specifically, animal, blood-injection-injury, and environmental, SAD presents at an earlier age of onset, and most cases of SAD begin before the age of 12 (Beesdo et al., 2009), with a mean age of onset of 8 years (Keller et al., 1992). In an epidemiological study in which 29,699 children and adolescents were randomly selected, the prevalence of SAD was 5.3% and was more frequent in the 6-9 years (7.2%) and 10-14 years (5.5%) age groups, than in the 15-18 years group (3%) (Mohammadi et al., 2020).

The avoidance of situations that involve separation from attachment figures or withdrawal from home restricts the child’s social relationships, has a negative impact on family functioning, and causes problems with school attendance. Symptoms of separation anxiety and school fears are strongly linked (Orgilés et al., 2009). A significant proportion of cases of school refusal present SAD: 22.2% in the clinical population (Allen et al., 2010) and 10.8% in the community population (Egger et al., 2003). Students with symptoms of separation anxiety have worse social functioning (Gonzálvez et al., 2019) and higher rates of school absenteeism (Fornander and Kearney, 2020).

The comorbidity of SAD with other disorders is high, with rates of up to 86% (Shear et al., 2006), especially with generalized anxiety disorder (74%) and with specific phobia (58%) (Verduin and Kendall, 2003). SAD is not only associated with other anxiety disorders, but also with various disorders such as Gilles de la Tourette syndrome (Eapen et al., 2018). The presence of SAD in childhood predicts the same disorder in adolescence (13-19 years) (Bittner et al., 2007) and is a powerful risk factor (78.6%) for the development of psychopathology in early adulthood (19-30 years) (Lewinsohn et al., 2008). SAD increases the risk of many disorders, including panic disorder, depression, and substance abuse (Aschenbrand et al., 2003; Hayward et al., 2004; Biederman et al., 2007; Brückl et al., 2007). Concerning SAD in adulthood, 36.1% presented it in childhood, especially women (Silove et al., 2010).

The prevalence of SAD in childhood, its serious negative repercussions in the family, school, and social spheres, its high comorbidity, and the risk of psychopathology in adolescence and adulthood advise early detection and early treatment of the disorder. In the evaluation of anxiety disorders, questionnaires and scales are widely used for their ease of administration, correction, and interpretation. From the point of view of multi-source evaluation, it is recommended to complement the child’s self-report with the parents’ report, especially considering that parents are the most important source of information for the clinician in the evaluation of the child’s emotional problems (Achenbach et al., 1987; Kazdin, 1988). Concerning SAD, children report discomfort more precisely, while their parents report disruptive behaviors (Allen et al., 2010). Parents often complain that their child cries, has tantrums, follows them around the house like their shadow, sleeps with them, refuses to participate in extracurricular activities, and performs other behaviors that affect family functioning.

There are parents’ versions of generic scales that assess anxiety disorders in childhood, including the SAD: the Multidimensional Anxiety Scale for Children (MASC; March et al., 1997), the Screen for Child Anxiety-Related Emotional Disorder (SCARED; Birmaher et al., 1997), and the Spence Children’s Anxiety Scale (SCAS; Spence, 1997). However, these scales, widely used in epidemiological studies, include only a reduced set of SAD items. In clinical contexts, it is useful to have specific instruments that collect the relevant aspects of SAD and that help plan therapy based on the particular characteristics of the case. There are two instruments for parents: the Separation Anxiety Avoidance Inventory - Parent Version (SAAI-P; In-Albon et al., 2013) and the Separation Anxiety Assessment Scale - Parent Version (SAAS-P; Eisen and Schaefer, 2005). The 12 items of the SAAI-P are limited to evaluating avoidance behavior, omitting fundamental dimensions such as worry and discomfort. The SAAS-P allows a more comprehensive evaluation, but its 34 items mix symptoms with triggering events of the disorder and safety signals that reduce separation anxiety. Moreover, both instruments evaluate separation anxiety indistinctly in childhood and adolescence: 4-15 years (SAAI-P) and 6-17 years (SAAS-P), although its manifestations vary with age. In a classic study, Francis et al. (1987) found that separation nightmares were more frequent in children (5-8 years), than in preadolescents (9-12 years) and adolescents (13-16 years); while separation distress was more common in children and preteens than in teens. According to the American Psychiatric Association (2000), young children do not usually express specific concerns, but as they get older, the concerns tend to become specified; for example, that parents have an accident. Adolescents, on the other hand, may deny separation anxiety, although it is reflected in the limitations to their independent activity, for example, refusing to leave the house.

The main objective of this research was to validate the parents’ version of the Children’s Separation Anxiety Scale (Méndez et al., 2014), which assesses separation anxiety symptoms in pre-adolescence, the life stage with the highest incidence of SAD. To this end, we carried out two studies with independent samples: in Study 1, we performed an exploratory factor analysis of the parent’s version of the scale (CSAS-P); In Study 2, we performed a confirmatory factor analysis, internal consistency, temporal stability, factor invariance and the difference in latent means, as well as the analysis of the differences between the child’s assessment (CSAS) and that of the parents (CSAS- P).

The CSAS-P is based on the three-dimensional theory of Lang (1968), which states that anxiety manifests through three related systems, giving rise to different response profiles depending on the predominant system: cognitive if concern has greater weight, psychophysiological if discomfort predominates, and behavioral if the most relevant aspect is escape/avoidance. Martínez-Monteagudo et al. (2012) state that it is appropriate to evaluate these three dimensions to plan the treatment. In this sense, the CSAS-P represents a contribution to the existing instruments, because the SAAI-P is limited to escape/avoidance behavior, a dimension that is not explicitly addressed in the SAAS-P (Figure 3). On another hand, the psychologists who assessed the original bank of items recommended including positive items to control the tendency to respond negatively and, contrary to expectations, when inverting the score, the positive items were not distributed among the negative factors, but rather emerged in a new factor, Calm (Méndez et al., 2008). In studies on the Personal Report of Confidence as Speaker (Paul, 1966) in the adolescent population, our research team found that confidence did not equate to a low level or absence of fear, but instead, self-confidence referred to the enjoyment of speaking. In other words, the experience was not only not scary or neutral, but reinforcing (Méndez et al., 1999, 2004).

Internal consistency for the CSAS-P and the Worry factor was good (Cronbach’s α > 0.80) and adequate for the other factors (Cronbach’s α > 0.70), values similar to those obtained with the SAAI-P, (0.75 ≤ α ≤ 0.87) and SAAS-P (0.70 ≤ α ≤ 0.84). The temporal stability of the CSAS-P was adequate, although it presented some deficiencies in the Calm and Distress factors (0.55 ≤ r ≤ 0.65). It should be investigated whether the joint completion of the scale by both parents introduces a source of variability in the answer in a significant proportion of cases because the degree of agreement between the mother and the father on the child’s internalized problems is modest (Stanger and Lewis, 1993).

Unlike SAAI-P and SAAS-P, the CSAS-P focuses on pre-adolescence, “a neglected population” (Cartwright-Hatton et al., 2006). A study with schoolchildren revealed that, from the age of 11, there was a generalized decrease in excessive fear, defined as twice the standard deviation above the mean in the Inventory of Fears, by Sosa et al. (1993), both on the intensity and the number of excessive fears; the fear of being separated from the parents increased notably in pre-adolescence: 4.48% (7 years), 9.76-11.11% (8-11 years), 5.10% (12 years) (Méndez et al., 2003).

Not only the increase in separation anxiety in pre-adolescence justifies the development of an instrument for this age group, but also the evolution of its manifestations. González (2003) analyzed the parents’ responses to the Early Onset Separation Anxiety Questionnaire, finding three dimensions: separation anxiety due to the loss or harm of a loved one (e.g., “If you or your partner have been admitted to the hospital, has your child shown excessive signs of anxiety?”); sleep-related separation anxiety (e.g., “If your child wakes up during the night, does he/she call you insistently and you have to go to his/her room to calm him/her down?”); and separation anxiety about everyday events (e.g., “If you are separated from your child to attend a social event [dinner, wedding, etc.], is your child eager for you to come home or does he/she feel the urge to phone you?”). That is, the dimensions referred to the situation (variable E), not to the reaction (variable R).

Our findings on age and gender differences in separation anxiety are consistent with the literature on the subject. The symptoms of separation anxiety diminish with age. Compton et al. (2000) found significantly higher levels in a community sample in the 8-12-year-old group than in the 13-19-year-old group. However, when the age range is reduced, the differences are usually small. The only difference of medium size that Orgilés et al. (2011) found was between the extreme ages of the recruited school sample, 8 and 11 years; younger children scored higher, especially in discomfort. Similarly, in the general population, separation anxiety symptoms are more frequent in the female gender (Orgilés et al., 2003), although again, this difference is small (Orgilés et al., 2012b).

The correlation between the child’s and parents’ scores was low. Studies of other separation anxiety scales with community pre-adolescent samples show similar results: r = 0.26 SAAS (Orenes, 2015), r = 0.36 MASC (Baldwin and Dadds, 2007), r = 0.27 SCARED (Cosi et al., 2010), and r = 0.16 SCAS (Ishikawa et al., 2014), data that corroborate the conclusion that “in general, parent-child and parent-parent concordance is low for internalizing symptoms, especially for domains that are relatively less observable by parents” (March and Parker, 2004, p. 48). Parent-child disagreement was greater in concern and lower in behaviors such as protesting, complaining, or crying, consistent with the greater degree of agreement in observable symptoms than in unobservable ones (Comer and Kendall, 2004).

Our research was carried out with a school population. Future studies should examine the psychometric properties of the CSAS-P with clinical samples, where parent-child agreement is usually higher. Arendt et al. (2014) obtained correlation coefficients of 0.45 and 0.60 for the SCAS Separation Anxiety Scale both in community and clinical samples.

In our study, carried out within the framework of the multi-source evaluation, and the child and the parents (or the main attachment figures) both participated but the evaluation was reduced to a single instrument. Future research should overcome this limitation and calculate the convergent validity of the CSAS-P with other measures of separation anxiety, as well as the sensitivity and specificity of the scale through a clinical interview.

The datasets presented in this article are not readily available because Institutional regulations. Requests to access the datasets should be directed to JG-F, josemagf@ua.es.

The studies involving human participants were reviewed and approved by University of Alicante. The patients/participants provided their written informed consent to participate in this study.

All authors participated in the design of the study, the analysis and interpretation of the data, the writing of the initial version of the manuscript, and approval of the final version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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