Separation anxiety is a normal part of development. It emerges during the second half year in infants. Separation anxiety reflects a stage of brain development rather than the onset of problem behaviors. On the other hand, prolonged separation anxiety that develops in school age children is considered an anxiety disorder by the American Psychiatric Association.
Normal separation anxiety
Developmentally normal separation anxiety usually begins somewhere around eight to 10 months and peaks by 18 months, after which it gradually diminishes until by age three. Only occasional bouts of separation anxiety then occur when the child is faced with new situations, such as starting preschool or the addition of a new baby to the family .
Before about six months of age, infants show little special attachment to a particular caregiver and no distress at being left alone. At about eight months, babies begin to react by crying and fussing whenever their primary caregiver leaves the room. Bedtimes may become a struggle, with the child refusing care from all but the primary caregiver and crying, fussing, and calling the caregiver when it is time to go to sleep . This unwillingness to be left alone can continue for many months.
When left with a babysitter, even a familiar individual that the infant formerly accepted, the child may scream and cry to exhaustion. This is likely to be due to a combination of separation anxiety and stranger anxiety , which arise at about the same time and has similar origins.
Separation anxiety is thought to develop because as babies mature mentally, they begin to recognize their caregivers as unique individuals. However, infants lack the mental capacity to understand that the caregiver still exists when out of sight. To the infant, once the caregiver cannot be seen, she is gone forever (lack of object permanence). This inability to project beyond what is immediately visible, coupled with the newly formed attachment to the caregiver, causes distress that is usually expressed by crying. Although this is a difficult stage for parents, the fact that a child fusses when the preferred caregiver leaves is a sign of healthy bonding and normal development. With experience and increased mental maturity, the child will eventually understand that he is not being abandoned permanently and that the caregiver will return.
Although separation anxiety is normal in infants and toddlers, cultural practices have an impact on the timing of its emergence and its extent. Babies who remain in constant contact with their mothers may develop separation anxiety earlier and possibly for more intense and prolonged periods than infants frequently cared for by a variety of different caregivers.
Separation anxiety disorder
Separation anxiety disorder occurs when older children refuse to leave a parent or other caregiver to whom they have become attached. Often separation anxiety disorder begins around age six or seven at a time when it can interfere with school attendance. School phobia can be a type of separation anxiety disorder.
Children with separation anxiety disorder repeatedly show at least three of the following behaviors at a developmentally inappropriate age:
- excessive distress at leaving home or leaving the primary caregiver, or even distress in anticipation of leaving
- excessive worry that something catastrophic will happen at home or to the caregiver while the child is away
- extreme fear that something will happen to them, such as getting lost or kidnapped, that will prevent their return to the caregiver
- unwillingness to be alone, even in familiar settings
- nightmares about separation from home and loved ones
- inability to stay at a friend's house overnight or go away to camp due to worry about what is happening at home
- physical complaints such as stomach pains, dizziness , headaches, or vomiting when faced with separation from home or caregiver
- refusal to attend school not related to events at school such as bullying or academic failure
- attachment to home or caregiver that interferes with social life and school attendance
Unlike developmentally normal separation anxiety, children do not outgrow separation anxiety disorder. This disorder is usually treated with a combination of behavioral and cognitive therapy. Behavioral therapy involves teaching parents and children strategies for overcoming stressful separation and may involve desensitization by gradual exposure to longer and longer periods apart. Cognitive therapy teaches children to redirect their thoughts and actions into a more flexible and assertive pattern. Family therapy may also be used to help resolve family issues that may be negatively affecting the child.
Separation anxiety disorder sometimes occurs in conjunction with other psychiatric disorders, such as pervasive developmental disorder, schizophrenia , other anxiety or panic disorders, and major depression. Depending on the diagnosis, children may also be treated with drugs to help alleviate these disorders. However, the use of antidepressants in minors is currently under review. In October 2003, the United States Food and Drug Administration issued an advisory indicating that children being treated with selective serotonin re-uptake inhibitor antidepressants (SSRIs) for major depressive illness may be at higher risk for committing suicide . A similar warning was issued in the United Kingdom. Parents and physicians must weigh the benefits and risks of prescribing these medications for children on an individual basis.
Parents are frequently frustrated by the intensity of their child's separation anxiety while an infant and toddler and believe that something is wrong with their child rather than accepting this natural stage of development. In school-age children, refusal to attend school due to separation anxiety disorder is common. This can lead to academic failure and difficulty in making friends and developing relationships outside the home.
Parents are distressed and concerned when their child is distressed. However, since anxiety disorders have an inherited component, in some families a parent will also have an anxiety disorder. The parent's anxieties can add to the child's concerns about separating, worsening the separation anxiety. In this case, family therapy as well as individual therapy for the parent and child may be appropriate.
When to call the doctor
Parents should call the doctor when a child in kindergarten or older shows extreme reluctance to separate from the parent to the point where it interferes with the child's normal life and social development. After a physical examination, a psychological evaluation that includes several assessments for anxiety and a behavioral checklist that evaluates the child's behavior at home and school should be done by a psychologist or psychiatrist with experience in separation anxiety.
Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, thus raising the levels of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
Greenberg, Mark T., Dante Cicchetti, and E. Mark Cummings. Attachment in the Preschool Years: Theory, Research, and Intervention. Chicago: University of Chicago Press, 1990.
Moore, David and James Jefferson. "Separation Anxiety Disorder." Handbook of Medical Psychiatry, 2nd ed. St Louis: Mosby, 2004 pp 52-54.
"Separation Anxiety." The Gale Encyclopedia of Childhood and Adolescence Detroit, MI: Gale Research, 1998.
American Academy of Pediatrics T 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098 Telephone: 847/434-4000 Fax: 847/434-8000 Web site: http://www.aap.org
"Other Mental Disorders in Children and Adolescents: Separation Anxiety Disorder." Mental Health: A Report Card from the Surgeon General [accessed 6 September 2003] http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html .
Tish Davidson, A.M.