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a developmental sequence. These tendencies seem to be hard-wired and seem to have a developmental purpose. Infants commonly show a fearful response to loud

noise or the sudden loss of physical support. Reluctance to be separated from

one’s caregiver is a normal, healthy response in young children and indicated

the development of healthy attachment. When a child starts to walk on its own,

fear of strange animals is an adaptive response. Performance anxiety can appear

sign that the preschooler has developed healthy attachments to loved ones. In

irritable and clingy as infants, have more trouble establishing a regular daily

schedule, and have more difficulty with transitions. (This is more enduring than

a couple of months of colic) Such children may be more vulnerable to separation

anxiety. Such a child may require more work and attention. However, having a

more difficult temperament, does not invariably lead to problems in later

common times for separation fears: eight months, twelve months and anywhere

between 18 months to three years. Separation anxiety generally emerges around

nine months of age and peaks around 12-24 months. The child’s crying and

clinging can express two different messages. First, the child may cry when the

parent leaves because they fear that the parent will be gone forever. The second

situation is when the child, often after a fairly good day, begins to cry when

the parent returns. This is because the parent’s return reminds the child of how

he or she felt when the parent left. Sometimes, children between one and two

years of age may walk or crawl away themselves, and then become anxious at the

separation they themselves have created. Separation anxiety generally decreases

between 2 and 3 years of age. The child often tends to be shy with strangers,

but morning separations become easier. The degree of separation difficulty may

vary from day to day. One day, the child may be anxious to go and another day,

clingy and sad. Many two-year-olds go through a phase when they prefer a

particular parent. This can exhaust the desired parent and make the other parent

feel unloved. The child has more of a drive toward independence. Still

very few or very frequent separations from loved ones experience the most

separation anxiety. Adults too experience anxiety when separated from loved

ones, but it is usually not so overwhelming. The adult has a better concept of

Factors that may contribute to

separation anxiety

• Tiredness
• Minor or major illness
• Changes in the household routine
• Family changes such as birth of a

  sibling, divorce, death or illness.

• Change in caregiver or routine at day

  care center.

• Parents usually are not the cause of

  the separation anxiety, but they can make things worse or better.

Factors that may reduce the chances of

developing separation anxiety

• Start occasionally using a babysitter

  by six months of age. This helps the child tolerate short periods away from

  the parent and encourages him or her to build trust in other adults.

• Even though children of this age do

  not engage in cooperative play, start contact with peers by 12 months. By

  age three, the child should be experiencing play groups.

• Some form of preschool may be helpful

  by age 3 or 4. This is especially important for children who seem overly

  dependent on their parents.

Supporting a child through periods of

separation anxiety.

• Positive experiences with caregivers,

  short times at first.

• Help child become familiar with new

  surroundings and people before actually leaving the child there.

• Rituals (bedtime and morning)
• “Lovie” or

  “Cuddly” Represents closeness to parents. If possible, allow the

  child to take the “Lovie” along.

• Do not give in. Let the child know

  that he or she will be all right.

• Remind the child of previous brave

  things he or she has done. Talk about how a fictional character might handle

  it.

• Let child know, in words he or she

  can understand that you appreciate how distressing it must be to be

  separated from loved ones. Understanding and acceptance, but not excessive

  sympathy.

• Never make fun of a child’s

  separation distress. Do not scold child for it.

• Do not bribe child to mask the

  distress. If you plan a special activity after you pick the child up, let it

  be unconditional.

• Focus on the positive things that

  happened in daycare. Don’t let them dwell on fears or imagination of what

  might happen.

• Minimize fears by limiting scary TV

  shows

• If it is an older child, consider

  introducing him or her to some of the children who are to be in the class

  and arranging play dates in advance.

• Preparing the child–reading books

  about going to preschool, pretending about going on voyages or quests.

• Make shopping for school supplies a

  special event just for that child.

• Expect a child to be more tired and

  possibly more irritable than usual when he or she starts Kindergarten or

  First grade for the first few weeks.

• When leaving, give a quick kiss and

  hug and cheerfully say goodbye.

• Don’t prolong your departure or come

  back several times.

• Don’t sneak out of the room.
• Even if you feel that a strict

  teacher or a bully might be part of the problem, keep your child going to

  school while these problems are being handled.

• If your child does stay home, do not

  make it an extra fun, gratifying day.

The Anxious Parent–Suggestions for

Teachers

• Teacher should introduce self to

  child and invite the child to play with toys or have a snack.

• Offer to have the parent stay a

  while, leave the child alone briefly with the teacher and then return.

• Suggest to the parent that he or she

  try role playing with the child to rehearse the separation.

• Teacher could have a ritual for the

  parent leaving the child.

• If the child is in an absolute panic,

  ask parent to stay until the child is quieter. Teacher should ask parent to

  comfort child in a firm, loving voice.

• Teacher should never criticize child

  for feeling sad or anxious.

Warning signals

• Child is inconsolable for more than 2

  weeks.

• Repeated physical complaints in the

  morning before preschool.

• Separation anxiety continuing into

  elementary school years and interfering with activities that other children

  do at that particular age.

• No separation anxiety at any time.
• School refusal in an older child or

  adolescent is often a more serious problem. In such a case, the parent

  should seek professional help early.

Separation Anxiety Disorder

Diagnosis and Symptoms: Severe,

than separation anxiety disorder)

Treatment

• Behavioral–Parents and child may

  benefit from counseling. Parent education and family therapy are often

  beneficial. In some cases, the child may also benefit from individual play

  therapy. Coordination is a key factor. The family should make sure that the

  mental health provider is willing to make the effort to coordinate between

  the pediatrician, the school and the family. Extended family may also need

  to be involved. The parents need to develop a consistent morning plan to

  help support the child in going to school. The school or day care providers

  and the school nurse are often included in the plan so that the responses to

  the child are consistent. If the child frequently complains of physical

  symptoms in the morning, the pediatrician should do a thorough physical exam

  to rule out any physical causes. Once this has been done, the pediatrician

  can reassure the parents and child if they call about the symptoms. If

  physical symptoms show a sudden change, the parents may need to have the

  child examined again. Once a particular symptoms has been carefully

  considered, it is often best not to do repeated medical evaluations of the

  same symptom. It is ideal if one or both parents are home and awake when the

  child leaves for school. If another caregiver is designated to see the child

  off to school, this individual should be involved in the therapy. I try to

  avoid home schooling in such children because it tends to become

  self-perpetuating. For many anxiety disorders, including phobias and COD,

  the best therapy is to face one’s fears consistently. Daily school

  attendance often leads to symptom remission.

   

• Medication. This is needed for a

  minority of children who have persistent symptoms, resistant to behavior

  modification and psychotherapy. There have been significant strides in

  knowledge of psychiatric medications for children. A number of studies have

  shown that Imipramine (Tofranil) can help separation anxiety disorder.

  However, one needs to follow EKGs (heart tests) and blood tests for safety

  reasons. Sometimes, high doses were necessary for improvement. In the past

  10-15 years, a new class of antidepressant medications has made treatment of

  childhood depression and anxiety disorders safer and more effective. The

  SSRIs, Prozac, Zoloft, Paxil etc. When used carefully and monitored closely,

  can help separation anxiety disorder. At this point, an SSRI would be the

  medication of choice instead of Imipramine. However it is important for the

  parent and the psychiatrist to discuss issues related to potential side

  effects of any antidepressant.

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