Anxiety in Young Children
E. Watkins, MD
Normal anxiety and fear tends to follow
a developmental sequence. These tendencies seem to be hard-wired and seem to have a developmental purpose. Infants commonly show a fearful response to loud
noise or the sudden loss of physical support. Reluctance to be separated from
one's caregiver is a normal, healthy response in young children and indicated
the development of healthy attachment. When a child starts to walk on its own,
fear of strange animals is an adaptive response. Performance anxiety can appear
in late childhood and social phobia in adolescence.
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
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
- 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
- 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
- Positive experiences with caregivers,
short times at first.
- Help child become familiar with new
surroundings and people before actually leaving the child there.
- Rituals (bedtime and morning)
- "Lovie" or
"Cuddly" Represents closeness to parents. If possible, allow the
child to take the "Lovie" along.
- Do not give in. Let the child know
that he or she will be all right.
- Remind the child of previous brave
things he or she has done. Talk about how a fictional character might handle
- 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
- Never make fun of a child's
separation distress. Do not scold child for it.
- Do not bribe child to mask the
distress. If you plan a special activity after you pick the child up, let it
- Focus on the positive things that
happened in daycare. Don't let them dwell on fears or imagination of what
- Minimize fears by limiting scary TV
- 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.
- Preparing the child--reading books
about going to preschool, pretending about going on voyages or quests.
- Make shopping for school supplies a
special event just for that child.
- 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.
- When leaving, give a quick kiss and
hug and cheerfully say goodbye.
- Don't prolong your departure or come
back several times.
- Don't sneak out of the room.
- 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.
- If your child does stay home, do not
make it an extra fun, gratifying day.
The Anxious Parent--Suggestions for
- Teacher should introduce self to
child and invite the child to play with toys or have a snack.
- Offer to have the parent stay a
while, leave the child alone briefly with the teacher and then return.
- Suggest to the parent that he or she
try role playing with the child to rehearse the separation.
- Teacher could have a ritual for the
parent leaving the child.
- 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.
- Teacher should never criticize child
for feeling sad or anxious.
- Child is inconsolable for more than 2
- Repeated physical complaints in the
morning before preschool.
- Separation anxiety continuing into
elementary school years and interfering with activities that other children
do at that particular age.
- No separation anxiety at any time.
- School refusal in an older child or
adolescent is often a more serious problem. In such a case, the parent
should seek professional help early.
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)
- 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 symptoms 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.
The Good-bye Book by
Into the Great Forest: A story for children away
from their parents for the first time by
Going to Daycare by Fred Rogers
Return to our Anxiety Home Page
Postal address: We have two locations in Baltimore County
Monkton Office16829 York Road/PO Box 544/Monkton,
Lutherville Office: 2360 West Joppa Road Suite
223/ Lutherville, MD
Please use telephone for appointments or medical questions.
Carol Watkins, M.D.
Glenn Brynes, Ph.D., M.D.
Rita Preller, LCSW-C
Copyright © 2004 Northern County Psychiatric
December 11, 2004