Coping with separation anxiety
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: My young son had a hard time separating from me when I dropped him off at daycare. I thought he would grow out of it, but he's become even more earful and upset when we're apart, and getting him to go to school has become a major battle. How can I help him?

A: Young children hate to be separated from their parents. These fears begin to appear around the first birthday, when children begin to sense that their parents will not always be with them. This normal separation anxiety peaks around age 2, but in most cases it gradually goes away by the time a child reaches 6 or 7. If the fear of being apart from parents persists in an older child and creates serious problems for the child or the family, it's called separationa n x i e t y d i s o r d e r. Fortunately, good treatments are available, and most families don't have to suffer long.

Separation anxiety disorder is often first diagnosed at age 6 or 7, when a child goes to school (see graphic). Some children develop the disorder around age 12, when they move from elementary to middle school. The problem is more common in girls, and it has been linked with depression and other anxiety disorders, especially social anxiety (incapacitating shyness) and panic disorder.

Children with separationanxiety disorder sometimes have nightmares about separation and may try to climb into bed with their parents at night. Some worry that they will be lost or kidnapped or that their parents will die when they're apart. Faced with separation, these children cry, cling to their parents, throw tantrums or develop physical symptoms -- headaches, stomachaches or sore throats.

Refusing to go to school is a common symptom of separation anxiety. Children with this problem delay leaving home, go only after much clinging and crying, and often leave school early. They constantly plead to be excused or complain of headaches or stomachaches on school days but not weekends. They dress slowly and miss the school bus. The symptoms are worst after weekends and vacations and may also increase after an illness, an accident, or a death in the family.

However, these symptoms can also stem from a different problem, such as depression, generalized anxiety or a fear of school itself. In school, children are subject to authority and rules made outside the family for the first time. They are constantly being compared with strangers and may be shamed by teachers or terrorized by bullies.

When leaving a child at the school bus or the school door, parents should always say goodbye. They will lose the child's trust if they sneak away while the child is distracted. Parents must remain calm because anxiety is contagious. Goodbye rituals like special hugs are reassuring. It's important to set limits, even if it means walking away from a screaming child and staying away. Usually the child will stop crying shortly after the parent leaves.

If the child is young and the symptoms are minimal, parents teachers, and school staff may be able to solve the problem.

In your situation, a consultation with a therapist makes sense. The therapist can help uncover and treat any underlying problems. You should also discuss the situation with teachers and school nurses so they don't overreact to physical complaints. In addition, parents can give their children points for going to school each day without crying, and then reward them with small prizes as the points accumulate. Allowing a child to stay home usually makes further school attendance more difficult and should be avoided whenever possible. If the problem is caused by a bully or critical teacher, a therapist or a parent can discuss the situation and help the child learn how to best respond

The most widely used treatments for separationanxiety disorder are behavioral and cognitive therapies. In general, these therapies focus on teaching the child to recognize and resist unrealistic fears. Relaxation training may help ease physical symptoms of anxiety, which can include stomachaches, headaches and shortness of breath.

Parents often find that learning about the problem helps them reassure and calm their child. Offering the child rewards, praise, and occasionally loss of privileges, sometimes helps, too. If family troubles are a source of the anxiety or the child is repeating the behavior of an anxious parent, joint family therapy that includes the child may help. Studies show that extra parental involvement, as well as individual or group cognitive behavioral therapy, can help ease separationanxiety disorder.

Separation anxiety is normal and universal in young children. But if it's unusually severe or persistent, it's abnormal. Fortunately, once separation-anxiety disorder is diagnosed, it can be treated.

Copyright 2007 the President and Fellows of Harvard College. Developed by Harvard Health Publications (www.health.harvard.edu). Distributed by UFS. Submit questions to harvard_ adviser@hms.harvard. edu.