The first days of school have long passed and parents, children and teachers have, in many cases, settled into a comfortable daily routine of work, school and/or child-care. Yet some children may still be expressing distress in saying good-bye to their parents/primary caretakers. How do we know when a child's difficulty separating from parents or primary caretakers has reached a level where help is warranted?

It's important to first understand separation anxiety in the context of normal child development and the purpose that it serves. Starting around 7 months of age, peeking at 10 to 18 months, and typically resolving around age 3 years, most children demonstrate upset feelings about separating from their caretakers. Children may cry and cling to caretakers when going to day care or school as well as when going to bed at night or even when parents simply go to another room in the house during the day. Separation anxiety is a sign that the child is attached to his or her primary caregiver and to a degree is adaptive in that it serves to keep the child safe from real harm (e.g., going off with a stranger etc.) In cases of typical separation anxiety, the child can calm down within 5 minutes of separating from their parents and positively engage in activities with his or her alternate caregivers and playmates.

Separation anxiety disorder may be diagnosed when a child becomes extremely distressed about separation and/or it begins to interfere significantly with his or her age appropriate activities that are important for social development. A child may take much longer than 5 minutes to calm down after parents leave, if at all. For the diagnosis to be made, the problem must be occurring consistently for longer than one month. Children may also worry about something bad happening to their attachment figure or something bad happening to themselves that would keep them from being with caregivers e.g., being kidnapped. Resistance or refusal to go to school, repeated nightmares about separation, and physical symptoms of anxiety (headaches, nausea, stomachache, etc.) are also common symptoms.

Both temperamental and environmental factors can make a child more vulnerable to separation anxiety disorder. Children with irritable and/or difficult to sooth temperaments often have greater difficulty with transitions including separations. Children who tend to be slow to warm up to new situations and people may also be more prone to separation anxiety difficulties. Major changes in the family (divorce, death, moving, or birth of a sibling) or in the childcare setting (staff turnover) can trigger separation anxiety episodes. A child's illness, tiredness and/or changes in routine can also increase his or her separation distress.

The following are strategies I often recommend to parents and teachers for supporting children in overcoming separation anxiety:

For Parents:

1. Take time to help your child become familiar with a new environment or caretaker via positive experiences before actually leaving him or her for the first time.
2. When leaving your child for the first few times in a new setting, plan to be gone for a relatively short period of time.
3. Have your child pick out a "transitional object" to keep with him or her while away from you. This may be a soothing object like a "lovie" or a small belonging of yours e.g., an inexpensive piece of jewelry. A small photograph can also be helpful.
4. Develop consistent rituals around saying goodbye and hello with your child, e.g., giving each other a high-five.
5. Empathize with your child's feelings, label them, and never belittle or scold your child for his or her fears. Empathy means expressing acceptance and understanding but is not necessarily overly sympathetic.
6. Remain calm and positive yourself about the pending separation and your child's distress about it. Help your child focus on the fun things he or she has to look forward to during the day while you are apart.
7. Plan a special activity for you and the child to do together after you are reunited.
8. When saying goodbye, never sneak out. Face the separation head on with a hug, kiss, special ritual, and cheerfully encourage your child to have a fun day. Don't return multiple times or prolong the goodbye.
9. Model handling separation bravely even if the separation is painful for you as well.
10. Remind your child about other separations they have handled bravely.
11. Think of fictional characters together that have also handled separations well.
12. Don't give in and allow your child to avoid the separation as it will positively reinforce the anxious behavior.
13. Prepare for expected separations by reading children's books about separation together, making visits to the new place together, and make getting prepared a fun activity e.g. special shopping trips for needed school supplies.
14. Role play saying goodbye bravely with your child while you are at home.
15. Expect set backs after disruptions in routine e.g., after holiday vacations or even long weekends.
16. Expect that your child will perhaps be more irritable while struggling with separation anxiety and do not become overly reactive or critical in response.
17. If there are physical symptoms of distress, have your child checked out by your pediatrician or family physician to rule out any medical conditions. Invite the physician to become a part of the intervention process.

For Teachers:

1. Teachers can meet the anxious child in advance of the first day of school and engage them positively e.g., with play or a snack.
2. Be flexible about allowing parents to stay a while in this introductory phase, to leave briefly and then return.
3. Teachers can also introduce rituals for children saying good-bye to parents and starting the day.
4. Encourage parents to soothe hysterical or panicked children with a firm and loving voice.

If separation anxiety continues to be extremely distressing or impairing, consult with a mental health professional to assess the situation and to work collaboratively with you, your child, your pediatrician, and alternate caregivers/teachers.

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