Separation Anxiety and Separation Anxiety Disorder:

What is separation anxiety?

Separation anxiety is a normal developmental stage experienced by a child when separated from the primary caregiver. It typically manifests itself as crying and distress when a child is away from a parent or from home.

As time goes by and a child learns to feel safe in a new environment and secure that a parent or caregiver will return after an absence, anxiety over separation should fade.

The typical sequence of child development and parent/child attachment is as follows:

• First few months: Babies don’t differentiate much among caregivers and usually can be calmed by any loving person, regardless of relationship. This is why new parents often get more emotional the first time they leave an infant with a babysitter or at day care than the baby does!
• 7-14 months: By about 7 months, babies realize that there’s only one Mommy and/or Daddy, but they don’t have a sense of time, so even if parents step into the next room for a minute, all the baby knows is that they’re gone — maybe forever! — and they’re going to cry or cling or do whatever it takes to keep that from happening. This phase is often called “stranger anxiety,” because even the happiest child becomes shy or fearful around everyone but the primary caregiver, and generally peaks before 18 months.
• Toddler/preschool years: Children can be anxious and become emotional when a parent or primary caregiver leaves but can be distracted by activities with the caregiver or other children.
• By age 5: Most children are secure enough to be left with a babysitter or dropped off at school without distress.

When feeling anxious about separation, young children exhibit many different behaviors, including:

• Crying or whining
• Clinginess (holding hand or leg, wanting to be held, hiding behind parent)
• Shyness
• Silence (instead of constant talking or babble)
• Unwillingness to interact with others, even if they are familiar (other parent, grandparent, friend)

Situations such as moving to a new home, a change in caregiver, or the birth of a new sibling can trigger or exacerbate separation anxiety.

Under normal circumstances, separation anxiety is the temporarily distressing result of something all parents want and seek to maintain: bonding with their children. Because babies bond to primary caregivers, then realize their own selfhood (that they’re not part of Mommy, so to speak) before they develop a sense of time or learn to trust that an absent caregiver will return, they become anxious when Mom isn’t around. As children develop a sense of safety and security in their homes and with their parents, begin to realize that people can leave and return, and gain confidence that caregiver who promise to come back will in fact come back, separation anxiety usually fades. KidsHealth for Parents (Nemours Foundation) has a site that discusses separation anxiety in detail and offers practical comments for parents and other caregivers.

Easing a child’s separation anxiety

Remember, separation anxiety is a normal stage of development. You won’t be able to head off every leg-cling or tearful goodbye, but you can help prepare your child for absences and do things to strengthen confidence and security about your return.

For babies and toddlers just learning to separate from primary caregivers, strategies include:

• Have babysitters come before the child develops stranger anxiety. If you leave your baby with a sitter for short periods when they respond well to any caring person, they’ll become accustomed to being with different people.
• Schedule separations after naps or feedings. Babies are more susceptible to separation anxiety when they’re tired or hungry.
• Have a consistent primary caregiver. If you hire a caregiver, try to keep him or her on the job from the baby’s infancy into toddlerhood.
• Practice separation for brief periods and short distances, increasing as the child can tolerate it. Praise the child for managing well. If your baby initiates separation by going into another (babyproofed) room, wait a few minutes before going after him; this will enhance his sense of independence.
• Keep the child in familiar surroundings when possible. For example, rather than dropping your child off at your sister’s house for the evening, have your sister come to your house.
• Make new surroundings familiar. Let your child become comfortable with new surroundings with you present. The first time you leave a child with a relative, for example, shouldn’t be the first time you and the child have visited that relative’s house. Allow your child to bring a favorite object of hers or yours.
• Develop a “goodbye” ritual. Rituals are reassuring and can be as simple as a special wave through the window or a special kiss.
• Have a calm, positive attitude. Babies and toddlers are sensitive to your moods and will pick up any tension in your voice, face, touch, or gestures. And don’t give in to the child’s tears, which are a ploy to get you to stay. If you keep running back when your baby fusses at being without you, that just reinforces the anxious behavior.  
• Tell your child when you go that you are leaving and that you will return, then go. Don’t stall or repeat goodbyes; that will just make your child more anxious and clingy. Tell the child where you’re going and when you’ll be back in terms he can understand. Conversely, don’t sneak away without saying goodbye; that will undermine the child’s sense that she can rely on you.

When your child is a little older, other things you can do to promote trust and a sense of security about separation include:

• Listen to your child’s feelings. Let your child know that you understand his feelings and reassure him that you’ll return. A statement such as “I know you’re feeling sad. I’ll miss you too” is more helpful than telling a child that he’s making a fuss over nothing.
• Read stories, role-play, and remind your child of successes. A number of children’s books incorporate the theme of separation anxiety such as The Kissing Hand by Audrey Penn, Big Truck and Little Truck by Jan Carr, and I Love You All Day Long by Francesca Rusackas. Talk with your child about times when she was brave or did something independently.
• Honor all commitments to your child, especially time commitments. Be especially attentive to picking up a child at the specified time or returning home when stated. Additionally, look for other ways to make and honor commitments, even small ones, to build trust and security.
• Plan and talk about enjoyable activities in advance. Help your child prepare to be away and anticipate positive outcomes. Let your child know how you can be reached if necessary.

9 Parent-Tested Ways to Ease Separation Anxiety (Scholastic.com) provides tips from parents who have helped their children overcome separation anxiety.

Again, most children outgrow separation anxiety by about age 5 and are able to experience time away from home and parents with little or no distress. Some children, however, experience a continuation or reoccurrence of separation anxiety during their elementary school years. When that anxiety is inappropriate or excessive, interferes with normal activities, and lasts for weeks rather than days, it may be a good idea to have a child evaluated for separation anxiety disorder.

Separation anxiety disorder

Separation anxiety disorder is described as excessive, age-inappropriate fear about being apart from family members, especially parents. Children with separation anxiety disorder fear being lost to their families or are sure something bad will happen to family members if they are separated from them. Unlike normal separation anxiety, which is a routine developmental stage in babies and toddlers, separation anxiety disorder generally appears in children of school age and represents fears that are exaggerated out of proportion to real situations or problems. It can interfere with or restrict a child’s normal activities to a significant degree.

Separation anxiety disorder affects about 4 percent of children 6-12 and a slightly lower proportion of adolescents, affecting girls and boys about equally.

Because children who develop separation anxiety disorder are unwilling to be away from family members, they may become isolated from other children and have difficult making friends and maintaining friendships. Resistance to attending school can lead to excessive absence and an impact on a child’s schoolwork and academic progress. Children with separation anxiety disorder are more at risk for panic disorders, agoraphobia, and full-blown school phobia. Additionally, left unattended, fears and uncertainty about trust, love and security can have a negative effect on a child’s ability to develop healthy, loving friendships and romantic relationships as an adult.

Causes and risk factors for separation anxiety disorder

Signs of separation anxiety disorder can be triggered by an event that the child experiences as traumatic, such as:

• a scary event that the child experiences personally (such as an earthquake) or hears about (e.g., a child abduction)
• a serious separation (e.g., a parent’s service in the military)
• stress in the family (such as a pending divorce, serious illness or death of a family member or beloved pet)
• a significant change (such as a new nanny, birth of a new sibling, or starting at a new school)
• an illness (major or minor).

On the physiological level, a chemical imbalance involving two chemicals in the brain (norepinephrine and serotonin) most likely contributes to separation anxiety disorder, as it does to other anxiety disorders. Studies of identical twins have suggested a genetic element to anxiety disorders, and children of parents with anxiety disorders are more likely to develop anxiety disorders of their own, whether the disorder is inherited or represents learned behavior from living in an anxious household. Separation anxiety disorder is a special risk for a child of an agoraphobic parent.

Other factors that may indicate a child at risk for separation anxiety disorder during school years include:

• An extremely close-knit family.
• A temperament that shows fear and withdrawal in new and unfamiliar situations.
• In girls aged 3 to 5, early temperamental traits of passivity and shyness.
• Insecure caregiver-child attachment in early years.

Symptoms of separation anxiety disorder

Separation anxiety manifests itself in a variety of physical and behavioral ways, including:

• Physical symptoms such as headaches or stomachaches, particularly when they occur persistently in anticipation of separation from parents
• Not wanting parents to be out of sight: following them around the house, requests to sleep in the parents' bed at night
• Nightmares about parents being gone or leaving
• Excessive worry about family members’ safety or the child’s own safety
• Excessive worry or panic when anticipating or experiencing a separation from home
• Refusal to go to school or other activities away from home

WorryWiseKids.org has a helpful list of red flags for separation anxiety disorder, and the Mental Health Foundation of New Zealand offers a detailed site on the condition, including a page on signs of separation anxiety disorder.

How can I tell if my child needs help?

Separation anxiety can be diagnosed as a disorder if symptoms persist longer than four weeks in a child older than 5. The time to seek professional medical help is when, for an extended period, a child fights being separated from a primary caregiver to the extent that he is refusing to go to school and other activities away from home and is not socializing with other children, and your efforts to make your child feel safe, secure and loved don’t seem to be working.

To diagnose separation anxiety disorder, a qualified mental health professional will perform a comprehensive psychiatric evaluation, which will determine if the child’s symptoms are the result of separation anxiety disorder, another anxiety disorder, or depression. The person making the diagnosis may also want to perform or refer the family for a family assessment. Early treatment can often prevent future problems.

See Frequently Asked Questions about Separation Anxiety Disorder (Psych Central) for a discussion of what does — and doesn’t — lead to a diagnosis of separation anxiety disorder.

Effects of separation anxiety disorder

Depending on the severity of the child’s anxiety, separation anxiety disorder can limit the child’s activity and involvement in life. Additionally, deep fears and uncertainty about trust, love and security can negatively impact a child’s ability to have healthy, loving relationships as an adult.

Some specific effects of separation anxiety disorder include:

• Isolation – children may limit activities due to fear of separation.
• Detachment – as they age, children may recognize their fears as unusual and separate themselves from others.
• Related disorders – agoraphobia, panic disorder and school phobia are far more likely to affect children who have separation anxiety disorder or a history of it.
• Difficulty developing relationships – without a sense of security and trust in other people, children may have a hard time connecting with others, whether it be friends, relatives or teachers.

Types of treatment for separation anxiety disorder

Parents are a crucial part of the treatment process for separation anxiety disorder, beginning with self-education about the illness. Becoming your own expert about separation anxiety disorder will help you empathize with your child, analyze your own behaviors and become more aware of your child’s triggers for anxiety. As a parent or caregiver, you can learn to listen to children, remain calm when children are anxious, remind them of past successes and future pleasures, set limits, and anticipate problems. You can also involve teachers and other school personnel in strategies to make school a more comfortable place for children with separation anxiety disorder.
Treatment may also  involve one or more forms of psychotherapy.. Therapies used in treating separation anxiety disorder, often employed in combination with each other, include:

• Cognitive behavioral therapy, in which the therapist teaches the child to challenge negative thoughts, develop new, positive thoughts, and practice alternative behaviors.
• Family therapy can help parents to manage their child's illness and learn effective parenting skills, while helping siblings to address the reality that one child’s problem affects everyone else in the family. It also helps create a sense of teamwork among family members to replace fault-finding and blaming behaviors.
• Play therapy uses toys, puppets, games, and art materials to help the child express feelings, and bibliotherapy  uses books and stories to model healthy separation behavior.

Children can also be taught relaxation techniques, such as deep breathing, self-soothing language and bio/neurofeedback.

Psych Central’s page (commercial site) on treatment of separation anxiety disorder focuses on the various forms of psychotherapy, and the Massachusetts General Hospital site on separation anxiety lists many helpful interventions for parents and teachers.

Related links for separation anxiety and separation anxiety disorder

General information

Separation Anxiety – Provides a multifaceted, readable description of symptoms and strategies concerning normal separation anxiety, that which doesn’t rise to the level of a disorder. (Children, Youth and Women’s Health Service, Australia)

Separation Anxiety in Young Children – Gives a detailed description of normal separation anxiety, with tips for parents and teachers. Also includes information about diagnosis and treatment for separation anxiety disorder. (Northern County Psychiatric Associates)

What is Separation Anxiety Disorder? – Examines separation anxiety disorder at home and at school for children and teenagers, discusses possible treatments and provides tips for home and school intervention. (Massachusetts General Hospital)

Conditions and Treatments: Separation Anxiety Disorder – Offers culturally sensitive information and commonsensical advice in a very detailed multipage site. (Mental Health Foundation of New Zealand)

Tips for parents

Separation Anxiety – Offers practical suggestions for parents dealing with separation anxiety disorder, as well as books to read to children. (KidsHealth / Nemours Foundation)

9 Parent-Tested Ways to Ease Separation Anxiety – Provides tips from parents who have helped their children overcome separation anxiety. (Scholastic.com)

Additional online resources for generalized anxiety disorder

Note: The following articles are longer and more technical, but can help you to delve deeper into the subject.

School Refusal in Children and Adolescents – Detailed article written for physicians about the problem of school age children refusing to go to school. Includes questions for parents to consider about fears and motivations of child. (American Academy of Family Physicians (AAFP))

Treatment of Children with Mental Disorders – Answers common questions about treatment and medications for children with mental disorders (in a question and answer format). (National Institute of Mental Health (NIMH))

Other resources that we used in writing this article

Separation Anxiety – Describes typical phase of separation anxiety in infants. (American Academy of Pediatrics (AAP))

The Anxious Child No. 47 – Provides an overview of separation anxiety disorder, symptoms and treatment options. (American Academy of Child and Adolescent Psychiatry (AACAP))

Separation Anxiety Disorder – Provides information on anxiety disorders of children and adolescents, including separation anxiety. (Anxiety Disorders Association of America (ADAA))

Ellen Jaffe-Gill, M.A ,Gina Kemp, M.A., Heather Larson, Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D. contributed to this article. Last modified on: 9/12/06.