At birth, infants have no concept of their caregivers as separate from themselves, so the old phrase, “out of sight, out of mind” applies to very young infants. At around 6-8 months, infants begin to understand that parents and caregivers are separate from themselves.

By about 9 months, the infant can call up a remembered mental image of the parent when they are not present and realize that the parent is GONE! They have no way of understanding when or even whether the parent will return.

This experience makes many infants and young children anxious. This can happen even when a parent or caregiver puts an infant to bed at night and is in the next room. This is the beginning of that period of infant development marked by “separation anxiety”(SA).

It can be a challenging time for both early childcare and education (ECE) professionals and parents, but remember that it is a sign of important developmental gains for the infant

Starting childcare and separating from a primary caregiver are stressful experiences and commonly cause SA in young children. Nearly all children, even those reared at home, will experience some developmentally-appropriate anxiety when separated from their primary caregivers, usually between 6-20 months, and peaking at 13-18 months.

How a child expresses his or her feelings in the ECE setting will depend on the child’s personality, previous experiences with separation, and the response of the adults in the child’s environment. Common ways of expressing anxiety over separation are crying, “clinging,” and having tantrums.

While some separation anxiety is normal, a child is identified as having Separation Anxiety Disorder (SAD) when she or he experiences excessive anxiety around separation for at least four weeks.

Intervention is imperative for these children because treatments are often very effective and can spare the child a great deal of distress as he or she grows. Anxiety disorders are commonly overlooked in children, which means children often do not get the interventions they deserve.

Between 8-12 percent of children suffer from anxiety severe enough to interfere with daily functioning, and this anxiety also can lead to other mental health problems. ECE settings can provide a valuable point of access to the mental health system for children who need mental health services and might not otherwise receive them.

The first sign of SAD usually is that the child refuses to go to childcare. The child may do this directly by verbalizing his distress, or indirectly by complaining of headaches or stomachaches.
The child also may have a temper tantrum in the morning while getting ready, or cling excessively when a parent attempts to leave him or her at childcare. The child with SAD does not have a specific fear, but rather a more general concern about separation from the primary caregiver. The anxious behavior occurs in any setting in which the child is separated from the caregiver.

To help the infant or toddler who is experiencing separation anxiety, and to prevent SAD in the childcare setting, providers should encourage parents to follow these recommendations:

• Accompany the child for a trial visit before starting in the childcare program. Another option is to have a phase-in period during which parent and child visit the program together over several days before the parent actually goes back to work.
• Stay with the child for a short period of time when dropping the child off at childcare.
• Make sure the child is not tired or hungry when dropped off at childcare.
• Resist the temptation to come back to check on the child once he/she has been left.
• Avoid sharing personal anxiety over separation with the child. That will only confirm what the child already fears.
• Learn the names of the caregivers and the other children, and know what the routine is. This will help the parent talk with the child about the new people in her or his life and about what to expect in the childcare setting.
• After picking the child up, spend time talking about what happened during the day and praise the child’s accomplishments.
• Offer the child a “transitional object” such as a photograph, blanket or cuddly toy that stands in for the parent. This helps remind the child that he or she is loved and the parent will return.
• Pay attention to and acknowledge one’s own feelings about leaving the child; this helps to process those feelings.

Can separation anxiety be prevented? There are techniques that can be used by caregivers to help children better understand separation.

• Play separation and return games like peek-a-boo and “where is the baby?” with infants and toddlers.
• Offer comfort during the day to the child with anxiety over separation. Praise the child for participating in activities.
• Identify the child’s interests and involve her or him in them immediately upon arrival.
• Avoid moving quickly or touching the child unless you are sure the child wants to be touched.
• Try “parallel playing” next to the child, and let the child direct any interaction between the two of you.
• Pair the children with a “buddy” who can help the child learn new routines and explain the physical environment.
• Say in words what you think the child is feeling, particularly if the child is sad or crying. Reassure the child that his or her parent(s) will return at a specific time.
• Read books like Are You My Mother? by P.D. Eastman, The Good-Bye Book by Judith Viorst, The Kissing Hand by Audrey Penn, and Benjamin Comes Back by Amy Brandt.
• Repeat familiar nap or mealtime routines from home.

After consistently applying these strategies for a month, talk with the family about seeking professional help if any of the following problems still exist:

• The child is inconsolable even after the parent has been gone for a long time;
• The child’s anxiety worsens; or
• The child’s anxiety becomes so overwhelming that the child is unable to do anything when the parent is not there.

Vickie Leonard, RN, FNP PhD, California Childcare Health Program

American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098; 847-434-4000; www.aap.org

Baby Center, www.babycenter.com/refcap/toddler/toddlerbehavior/12652.html

Kids Health, www.kidshealth.org/parent/emotions/feelings/separation_anxiety.html

National Network for Childcare, www.nncc.org/Guidance/dc11_ease.transit.html

Zero to Three, Object Permanence and Separation Anxiety, www.zerotothree.org/ztt_professionals.html