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Some degree of separation anxiety is a sign that
the preschooler has developed healthy attachments
to loved ones. In many cases, it stops within 3-4
minutes after the parent leaves.
Temperament - Some
children seem more 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 childhood.
Normal Development of Separation -
Most 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
transition times can be difficult, and lead to temper
tantrums.
For toddlers, those who have had either 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 time and has had more experience dealing successfully
with separation.
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.
1. Positive experiences with caregivers, short times at first.
2. Help child become familiar with new surroundings and people before actually
leaving the child there.
3. Rituals (bedtime and morning)
4. "Lovie" or "Cuddly" Represents closeness to parents. If
possible, allow the child to take the "Lovie" along.
5. Do not give in. Let the child know that he or she will be all right.
6. Remind the child of previous brave things he or she has done. Talk about how
a fictional character might handle it.
7. 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.
8. Never make fun of a child's separation distress. Do not scold child for it.
9. Do not bribe child to mask the distress. If you plan a special activity after
you pick the child up, let it be unconditional.
10. Focus on the positive things that happened in daycare. Don't let them dwell
on fears or imagination of what might happen.
11. Minimize fears by limiting scary TV shows
12. 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.
13. Preparing the child--reading books about going to preschool, pretending about
going on voyages or quests.
14. Make shopping for school supplies a special event just for that child.
15. 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.
15. When leaving, give a quick kiss and hug and cheerfully say goodbye.
16. Don't prolong your departure or come back several times.
17. Don't sneak out of the room.18.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.
18. If your child does stay home, do not make it an extra fun, gratifying day.
The Anxious Parent--Suggestions for Teachers
1. Teacher should introduce self to child and invite the child to play with toys
or have a snack.
2. Offer to have the parent stay a while, leave the child alone briefly with
the teacher and then return.
3. Suggest to the parent that he or she try role-playing with the child to rehearse
the separation.
4. Teacher could have a ritual for the parent leaving the child.
5. 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.
6. Teacher should never criticize child for feeling sad or anxious.
Warning signals
7. The child is inconsolable for more than 2 weeks.
8. Repeated physical complaints in the morning before preschool.
9. Separation anxiety continuing into elementary school years and interfering
with activities that other 10.children do at that particular age.
11. No separation anxiety at any time.
12. School refusal in an older child or adolescent is often a more serious problem.
In such a case, the parent 13.should seek professional
help early.
14. Separation Anxiety Disorder
Diagnosis and Symptoms
Severe, persistent anxiety about being separated from home or parents. The anxiety
must be severe enough to interfere with normal activities. The child generally
shows distress when separated from parents, and worries that the parents may
suffer harm when away from the child. When separated, the child may have nightmares
and sleep problems. Physical symptoms such as nausea, headaches and abdominal
pain may occur before or during a separation. The diagnosis is not made if the
symptoms are part of another disorder such as Pervasive Developmental Disorder,
or a psychotic disorder. (These diagnoses are rarer and usually more serious
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 symptom 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.
Courtesy of : Carol
E. Watkins. MD (Pyschiatrist) in the U.S.A.
Suggested Books
The Good-bye Book by Judith
Viorst
Into the Great Forest: A
story for children away from their parents for the first time by Irene Marcus
Going to Daycare by Fred
Rogers
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