Child is inconsolable for more than 2 weeks.

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)

Treatment

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.