Separation anxiety: Separation anxiety is crying when a parent leaves the room. It is normal when it starts at about 8 mo, peaks in intensity between 10 and 18 mo, and generally resolves by 24 mo. It should be distinguished from separation anxiety disorder (see Mental Disorders in Children and Adolescents: Separation Anxiety Disorder), which occurs at an older age, when such a reaction is developmentally inappropriate; refusal to go to school (or preschool) is a common manifestation.

Separation anxiety occurs at a time when infants start to become emotionally attached to their parents. Because they have no object permanence (incomplete memory and no sense of time), children fear that the departure of their parents is permanent. Separation anxiety resolves as children develop a sense of memory; they can keep an image of their parents in mind when the parents are gone and can recall that in the past, the parents returned.

Parents should be advised not to limit or forego separations in response to separation anxiety; this response could compromise the child's maturation and development. When parents leave the home (or leave the child at a child care center), they can try the following strategies:

• Encouraging the person caring for the child to create distractions
• Leaving without responding at length to a child's crying
• Remaining calm and reassuring
• Establishing routines at separations to ease the child's anxiety
• Feeding the child and letting the child nap before parents leave (because separation anxiety may be worse when a child is hungry or tired)

If the parents must momentarily go to another room in the home, they should call to the child while in the other room to reassure the child. This strategy gradually teaches the child that parents are still present even though the child cannot see them.

Separation anxiety causes no long-term harm to children if it resolves by age 2 yr. If it persists beyond age 2, separation anxiety may or may not be a problem depending how much it interferes with the child's development. For children, feeling some fear when they leave for preschool or kindergarten is normal. This feeling should diminish with time. Rarely, excessive fear of separations inhibits children from attending child care or preschool or keeps them from playing normally with peers. This anxiety is probably abnormal (separation anxiety disorder—see Mental Disorders in Children and Adolescents: Separation Anxiety Disorder). In such cases, children require medical attention.

Stranger anxiety: Stranger anxiety is manifested by crying when an unfamiliar person approaches. It is normal when it starts at about 8 to 9 mo and usually abates by age 2 yr. Stranger anxiety is linked with the infant's developmental task of distinguishing the familiar from the unfamiliar. Both the duration and intensity of the anxiety vary greatly among children.

Some infants and young children show a strong preference for one parent over another at a given age, and grandparents may suddenly be viewed as strangers. Anticipating these occurrences during well-child visits helps prevent misinterpretation of the behavior. Comforting the child and avoiding overreaction to the behavior are usually the only therapy needed.

Common sense should dictate management. If a new sitter is coming, having that person spend some time with the family before the actual day makes sense. When the event arrives, having parents spend some time with the child and sitter before they leave is prudent. If grandparents are coming to watch the child for a few days while parents go away, they should arrive a day or two early. Similar techniques can be used in anticipation of hospitalization.

Stranger anxiety of pronounced intensity or extended duration may be a sign of more generalized anxiety and should prompt evaluation of the family situation, parenting techniques, and the child's overall emotional state.

Last full review/revision February 2010 by Eve R. Colson, MD; Rachel L. Chapman, MD; Melissa R. Held, MD

Content last modified February 2012