Child and Adolescent Psychiatry Consulting

Fears of separation from a caregiver is a  normal part of development that occurs in all children to varying degrees between infancy and age 6. Devlopmentally normal separation anxiety is commonly  first seen around 8-10 months of age, when an infant becomes anxious when meeting strangers (this is called stranger anxiety ). Children also may become mildly anxious around 18-24 months of age, when they are increasingly exploring their world but wanting to return to their caregiver frequently for security.

Children with separation anxiety disorder have separation worries that are excessive and much greater than their peers. These worries can overwhelm a child, even when separation is brief (like going to one’s own room to sleep, or staying at home while a parent runs an errand. The child’s fears may appear to be irrational, such as the fear that the parent may suddenly die or become ill. Young people with separation anxiety disorder often go to great extremes to avoid being apart from their home or caregivers. They may protest against leaving a parent’s side, refuse to play with friends, or complain about physical illness at the time of separation. It is not uncommon for a child to tolerate separation from one parent more easily than separation from the other parent.

• Diagnosing separation anxiety disorder can be challenging because children with separation anxiety disorder may have more than one anxiety disorder.
• Children with separation anxiety disorder frequently have physical complaints, which also may need to be medically evaluated.
• A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top

At Home, children with separation anxiety disorder may exhibit some or all of the following:

• Consistent and extreme worry and fear when separating from home or primary caregiver. Children also may be extremely frightened and worried when they anticipate separation and may be unwilling to be alone.
• Persistent worry and fear that something bad may happen to their parent or to themselves. They may worry about a parent becoming sick or getting hurt. They also may worry about getting lost if separated.
• Refusal to attend school often develops, due to worries about separating
• Refusal or reluctance to participate in ordinary outings or activities . The child may not want to go out to dinner, meet friends to play, or engage in after- school programs.
• Difficulty sleeping alone . Children may insist that a parent sleep with them or may insist on sleeping with the parent in the parent’s bed.
• Scary dreams about being separated
• Frequent physical complaints at times of separating . Children with separation anxiety disorder often complain about stomach aches, headaches, or other physical discomforts when they know they will have to separate.

If left untreated, the condition may lead to considerable limitations in other areas of the child’s life. Peer relationships, school functioning, and family functioning may suffer, or depression may develop. In some situations, if a child believes there is no way to reduce extreme anxiety, thoughts of self-harm or not wanting to be alive may develop. top

At School a child with separation anxiety disorder may exhibit some or all of the following:

• Difficulty transitioning from home to school . Children may have great trouble separating from their parents in the morning. This may lead to late arrival times, long and tearful morning drop-offs, or tantrums at school.
• Refusal or reluctance to attend school . Anxiety associated with this disorder is powerful and may lead a child to insist on staying at home.
• Avoidance of activities with peers. Any additional time at school may be resisted.
• Low self-esteem in social situations and academic activities
• Difficulty concentrating due to persistent worry, which may affect a variety of school activities, from following directions and completing assignments to paying attention
• Other conditions, such as generalized anxiety disorder, panic disorder, phobias, or depression , which may also be present, compounding any learning challenges.
• Learning disorders and cognitive problems, which are often overlooked in this population. A child’s difficulties or frustrations in school should not be presumed to be due entirely to the separation anxiety disorder. If the child still has academic difficulty after symptoms are treated, an educational evaluation for learning disabilities should be considered. A child’s repeated reluctance to attend school may be an indicator of an undiagnosed learning disability.
• A child or adolescent with separation anxiety disorder may try to hide symptoms while at school and may appear to have more symptoms at home than at school. For other children, the symptoms are evident at school because of the child’s difficulty leaving a parent and the resulting impact on school attendance.

At the Doctor’s Office

A child’s symptoms of separation anxiety disorder may be evident during an office visit when a child refuses to meet with the clinician alone, though it is not uncommon for a child to be nervous at the doctors’ office, so this is not an enough of a presentation to diagnose a child with separation anxiety disorder.

The following challenges are common when diagnosing and treating a child or adolescent with separation anxiety disorder:

• Symptoms vary and their appearance may change as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis.
• Other conditions may look like separation anxiety disorder .
• Depression often co-occurs in these children
• Frequent physical complaints such as stomach aches, headaches, nausea, or injury, often associated with separation anxiety disorder, must be considered to determine whether they complaints warrant further medical investigation.
• Children may have difficulty talking about the fears of separation. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge. For example, to elicit information from a child, clinicians might ask, “What do you worry about when you go to bed alone ?”
• Children may be unaware, or unwilling to admit , that their behavior may indicate symptoms of a disorder
• Families may need to be coached about what they can reasonably expect from their child. Children who suffer from separation anxiety disorder will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms.