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Separation anxiety

Separation anxiety is a developmental stage during which the child experiences anxiety when separated from the primary caregiver (usually the mother).

Causes, incidence, and risk factors

As infants develop, they experience various emotions, usually in a predictable order. Before 8 months, infants are so new to the world that they have little knowledge of what is ordinary and what may be dangerous, so new situations or experiences seem usual, and not frightening.

In normal development, during this early period the infant becomes familiar with the home environment, and feels comfortable when parents or other known caretakers are present. After this time, lack of familiarity often produces fear because the infant recognizes that something unusual is going on.

From 8 - 14 months, children often become frightened when they meet new people or visit new places. They recognize their parents as familiar and safe. When separated from their parents, particularly when away from home, they feel threatened and unsafe.

Separation anxiety is a normal developmental stage. It helped keep our ancestors alive and helps children learn how to master their environment.

It usually ends when the child is around 2 years old. At this age, toddlers begin to understand that parents may be out of sight now, but will return later. There is also a normal desire to test their independence.

To get over separation anxiety, children must:

  • Feel safe in their home environment
  • Trust people other than their parents
  • Trust that their parents will return

Even after children have successfully mastered this developmental stage, separation anxiety may return during periods of stress. Most children will experience some degree of separation anxiety when in unfamiliar situations, especially when separated from their parents.

When children are in situations (such as hospitals) and are experiencing stress (such as illness or pain), they seek the safety, comfort, and protection of their parents. When parents cannot be with their children in these situations, the children experience distress.

This is why it is important to stay with your child as much as is possible during any medical procedures. Your presence can actually reduce the amount of pain the child experiences, as anxiety of any kind makes pain worse.

Symptoms

  • Excessive distress when separated from the primary caregiver
  • Nightmares
  • Reluctance to go to school or other places because of fear of separation
  • Reluctance to go to sleep without the primary caregiver nearby
  • Repeated physical complaints
  • Worry about losing or harm coming to the primary caregiver

Signs and tests

There are no tests for this condition, because it is normal.

If severe separation anxiety persists past age 2, an evaluation with a psychiatrist may be needed to determine if the child has an anxiety disorder or other condition.

Treatment

No treatment is necessary for ordinary separation anxiety.

Parents can help their infant or toddler learn to adjust to their absence by letting trusted caregivers babysit the child. This helps the child learn to trust and bond with other adults and understand that their parents will return.

If medical procedures are needed while a child is in this stage, it is helpful for a parent to go with the child whenever possible. When a parent cannot come with the child, exposing the child to the situation beforehand is helpful; for example, visiting the doctor's office before a test. When this is not possible, the child may display severe anxiety by crying, resisting treatment, begging, and screaming.

Some hospitals provide Child Life specialists who can explain procedures and medical conditions to children of all ages. If your child is particularly anxious and needs significant medical care, it may help to ask your health care provider about such services.

When separation from parents is necessary, but exposing the child to it beforehand is not possible (such as for surgical treatment), many physicians will recommend the child take mild sedating or tranquilizing medications to help reduce the trauma.

Explain the situation and experience to the child and assure him or her that a parent is waiting, and specifically, where the parent is waiting.

For older children who have not outgrown separation anxiety within the normal developmental timetable or who have regressed to it under stress, effective treatments may include:

  • Anti-anxiety medications
  • Changes in parenting techniques
  • Counseling for the parents and child

Treatment for severe cases may include:

  • Family education
  • Family therapy
  • Individual psychotherapy

Expectations (prognosis)

Young children with symptoms that improve after age 2 are normal, even if some anxiety comes back later during stress. When separation anxiety occurs in adolescence, it may signal the development of an anxiety disorder.

Calling your health care provider

Call your health care provider if your child has significant separation anxiety after age 2.

References

Stafford B, Boris NW, Dalton R. Anxiety disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 24.

Feigelman S. The first year. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 8.

Updated: 4/26/2010

Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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