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Separation and Stranger Anxiety

by Deborah M. Consolini, MD

As infants develop intellectually and emotionally, they quickly learn to recognize and become attached to their parents or primary caregivers. As this bond strengthens, infants often become anxious or afraid whenever parents leave or strangers appear. These fears are a normal part of infant development and should resolve with time.

Separation anxiety

Separation anxiety is a stage of normal development. During this stage, children develop anxiety when they are separated from their parents or primary caregivers. Separation anxiety typically begins when children are about 8 months old and becomes most intense when children are 10 to 18 months old. Children who are 8 to 18 months old often become frightened when they meet new people or visit new places. When separated from their parents or caregivers, particularly when away from home, they feel threatened and unsafe. They look to their parents and caregivers for safety and reassurance. Children this age who cry when their parents or caregivers leave the room are not "spoiled." Rather, crying indicates the children have developed a sense of attachment to their parents or caregivers. Crying in this situation is a positive reaction, because children who are not attached to their parents or caregivers do not cry when they leave the room.

Parents or caregivers may try playing peek-a-boo with children this age to reassure children that out of sight does not mean gone forever.

Separation anxiety continues until children are about 24 months old. At this age, children have learned object permanence and have developed trust. Object permanence is the knowledge that something (such as their parents) still exists even when it is not seen or heard. Separation anxiety resolves because children have learned that their parents or caregivers still exist even when they cannot be seen. Children have learned to trust their parents or caregivers will eventually return.

Usually, separation anxiety is not a cause for concern and does not require evaluation by a doctor.

Separation anxiety differs from separation anxiety disorder (see Separation Anxiety Disorder), which occurs in older children. Children with this disorder typically refuse to go to school or preschool. If severe, separation anxiety disorder may interfere with a child's normal development.

Parents should not limit or give up their separate activities in response to a child’s separation anxiety because doing so could interfere with the child's maturation and development.

When parents are ready to go out or leave the child at a child care center, they can try the following:

  • Making sure that any temporary caregiver is familiar to the child

  • Encouraging the person caring for the child to distract the child with toys, a game, or another activity as the parents leave

  • Limiting their response to the child's crying before they leave

  • Remaining calm and reassuring

  • Establishing routines at separations to ease the child's anxiety

  • Feeding the child and letting the child nap before they leave (because separation anxiety may be worse when a child is hungry or tired)

If a child cries when a parent goes to a another room in the home, the parent should call to the child from the other room, rather than immediately return to comfort the child. This response teaches the child that parents are still present even though the child cannot see them.

Separation anxiety that lasts beyond age 2 years may or may not be a problem depending on how much it interferes with the child's development. For example, most children feel some fear when they begin preschool or kindergarten. If they are able to attend the program and their fear decreases with time, this fear is not an expression of separation anxiety. However, separation anxiety that keeps a child from attending child care or preschool or from playing normally with peers can be a sign of separation anxiety disorder. In such cases, children should be seen by a doctor.

Stranger anxiety

Children with stranger anxiety may cry when an unfamiliar person approaches. This anxiety is normal when

  • It begins at about age 8 to 9 months.

  • It resolves by age 2 years.

Stranger anxiety is related to infants' learning to distinguish the familiar from the unfamiliar. How intense it is and how long it lasts vary greatly among children.

Some infants and young children show a strong preference for one parent over another at a given age. They may suddenly see grandparents as strangers. Parents need to be aware that this behavior is to be expected and let grandparents know about it. Thus, misinterpretation of the child’s behavior can be avoided. Comforting the child and avoiding overreaction to the behavior are usually the only treatment needed.

If a new sitter is coming, having the sitter spend some time with the family before the actual day is a good idea. When the day arrives, parents should plan to spend some time with the child and the sitter before they leave. Similarly, if grandparents are coming to watch the child for a few days while parents go away, they should arrive a day or two early.

If a child needs to have a diagnostic test or be hospitalized, taking the child to the doctor’s office or hospital beforehand to see what it is like may help. Parents should also reassure the child that they will be waiting nearby and should specify exactly where.

If stranger anxiety is very intense or lasts a long time, it may be a sign of more generalized anxiety. In such cases, the child should be seen by a doctor promptly. Doctors evaluate the family situation, parenting techniques, and the child's overall emotional state.