BEHAVIOR:
ASK THE EXPERTS

SEPARATION ANXIETY—OR SOMETHING MORE?

Q How do I treat severe separation anxiety in an 8-year-old boy? School and day camp are the main triggers, but fear prevents him from attending most activities in other settings without at least one parent present. At times, he even resists leaving home for a short outing with his parents and develops a stomachache, chills, or a general complaint of "not feeling well."

Talk therapy and relaxation techniques have not helped. What's more, the child has begun lashing out physically and verbally at his parents and throws violent tantrums when confronted with stressful situations, such as attending a birthday party or going to a friend's house to play. The boy—formerly a compliant child—now displays frequent, generalized oppositional behavior. He is not receiving any medication at this time.

Bram Greenberg, MD
Allentown, Pa.

A Your working diagnosis seems on target: separation anxiety. Always examine the diagnostic criteria, however, to be sure. Recall that a diagnosis of separation anxiety requires at least three of the following:

• recurrent excessive distress when anticipating separation

• persistent reluctance to go to school or anywhere else because of separation fears

• persistent reluctance to be left alone or without major attachment figures in other settings

• repeated physical symptoms when separation is anticipated

• persistent worrying about losing a major attachment figure

• persistent worry about an untoward event that will lead to separation from a major attachment figure

• persistent reluctance to go to sleep without being near a major attachment figure

• repeated nightmares about separation

The fact that the child's tantrums and explosive behavior are directed at his parents makes this case slightly atypical. Also, you do not mention the child's prior history. Is this a new phenomenon that has appeared since he turned 8? Did something else change in the family—a new home, new school, new sibling, or one of his parents starting a new job—that could be triggering his anxiety? The boy's previously compliant disposition is not the usual prelude to explosive behavior.

Ross Greene has written an excellent book called The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children (2nd ed., New York, Perennial, Harper/Trade, 2001). In it he writes about the role temperament often plays in explosive behavior in children. In that light, it is hard to formulate a way in which this child's behavior could have appeared out of nowhere. It would be helpful to know if your 8-year-old patient was a persistent, nonapproaching, poorly adaptable toddler.

I suggest that you obtain a more detailed history to rule out other possible diagnoses related to adjustment to a stressful event, a new source of anxiety, or a new-onset phobia. In cases like this, I have had good results using Dr. Greene's model of collaborative problem solving, which advises partnering with the child to solve his underlying problem, particularly as it relates to his explosive behavior.

Marilyn Augustyn, MD

DR. AUGUSTYN is assistant professor and director of training, division of developmental and behavioral pediatrics, Boston Medical Center.

Editors' note: For more on the treatment of anxiety disorders, see "Welcome advances in treating youth anxiety disorders."

CO-SLEEPING WITH GRANDMOTHER SPARKS FAMILY CONFLICT

Q A family in my practice has a 6-year-old boy who is entering first grade this fall. He has been sleeping with his grandmother whenever she visits since he was about 18 months old. She visits at least once a month. The other children in the family never sleep in the same bed with her. When the boy turned 4, the family began hinting that he was getting too old to sleep in the same bed with his grandmother, but the grandmother ignored them and they didn't press the issue.

Now, the parents feel the need to stop the boy and his grandmother sleeping together. Whenever they demand that the boy sleep in his own bed, however, both the boy and his grandmother start to cry. She accuses the parents of being mean or trying to punish her. Because no one in the house is able to sleep until the grandmother is allowed to bring the child into the guest room, the parents eventually relent.

When the grandmother is not visiting, the boy sleeps in his own bed every night without incident and does not ask at bedtime to sleep with the parents. On the rare occasions when he does come into the parents' bed in the middle of the night, he is easily taken back to his own bed.

The parents think that the boy would not protest so much against giving up co-sleeping with his grandmother if the grandmother didn't persist. Their major question is: At what age should a child not be allowed to sleep with an adult of the opposite sex? They also wonder, at what point will they have to force the issue, even if it means the grandmother storms out of the house in the middle of the night? They don't suspect sexual abuse, but it does seem strange to them that the grandmother is so emotionally invested in sleeping with her grandson.

Elizabeth Rashley, MD
Statesville, N.C.

A When should a child stop sleeping with an adult relative of the opposite sex? The answer has many qualifications and layers, which I will try to simplify. Once the issue of sexual abuse is removed, as in this case, the next question is what does this behavior mean to the child, parents, and grandmother in terms of culture and sexuality. In many cultures it is common for children to sleep with parents and/or grandparents. When it is culturally acceptable, children and adults of the opposite sex sleep together without sexual excitement, sexual need, or excessive personal need. We don't know in this family's case if it is a culturally accepted practice for a grandmother to sleep with her grandchild. Even if it is, family disagreement can occur if the younger generation rejects "old country" cultural practices or if family members come from different cultures with different attitudes about practices such as co-sleeping.

When culture is not a factor, concern remains about whether co-sleeping is overstimulating for the child. At some point in a child's development, around 4 to 7 years of age, what was previously comfortable can become overstimulating and sexually exciting. The question of whether co-sleeping is harmful in this case can only be answered by observing the child for evidence of overexcitement—such as uncontrollable giggling; overactivity; interest in talking about seeing, touching, or cuddling close to the grandmother's breast; or even an erection.

Another potential concern is whether the grandmother has inappropriate, excessive needs for physical or emotional intimacy that are met by sleeping with her grandchild. If the child is overstimulated or if the grandmother is lonely and has few social outlets, or tends to infantilize the boy, it may be appropriate to make a change. In any case, the adults should discuss the decision privately to minimize the uproar, which may make the child feel guilty and anxious. They can tell the child that big boys sleep in their own beds. Also, the grandmother should be urged to support her grandson's healthy, natural need to mature and separate.

If the above conditions are not present and the relationship between the grandmother and the child is mutually rewarding and comfortable, I would not change the sleeping arrangements until the child matures and no longer wishes to sleep with his grandmother. If the parents are uncomfortable with this advice, and the grandmother will not accommodate their wishes, the other practical solution is for the grandmother not to sleep over. The worst decision is to "have it out" every time the grandmother sleeps over.

Barry Zuckerman, MD

DR. ZUCKERMAN is chief of pediatrics and medical director, Boston Medical Center, and professor and chairman, department of pediatrics, Boston University School of Medicine.

Questions wanted!

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• unusual behavior

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Behavior: Ask the experts. Contemporary Pediatrics 2002;9:36.