Homesickness

INTRODUCTION — Homesickness is the distress and functional impairment caused by an actual or anticipated separation from home and attachment objects such as caregivers [1]. It is characterized by acute longing and preoccupying thoughts of home.

Almost all children, adolescents, and adults experience some degree of homesickness when they are apart from familiar people and environments. In some individuals, the subjective distress and level of impairment related to this separation may be extreme, thereby interfering with social, academic, or vocational functioning [2].

Primary care providers can help caregivers understand the etiology of homesickness, identify which children and adolescents are at highest risk, and develop strategies for prevention and/or treatment. An overview of homesickness, including techniques for prevention with planned separations, such as summer camp and university study, and treatment strategies for unanticipated or traumatic separations, such as hospitalization, will be presented below.

DEFINITIONS — Homesickness is defined as the distress and functional impairment caused by an actual or anticipated separation from home and attachment objects such as caregivers [1]. Severe homesickness is classified as an adjustment disorder with mixed anxiety and depressed mood according to the American Psychiatric Association taxonomy (diagnostic code F43.23) [3].

Homesickness is characterized by recurrent cognitions focused on home (eg, caregivers, house, loved ones, home cooking, pet); it is always precipitated by an actual or anticipated separation from home. These features distinguish homesickness from other adjustment disorders, anxiety disorders, and mood disorders, as well as from the separation anxiety felt by children when caregivers leave home (eg, because of divorce, military service, etc) [4,5].

EPIDEMIOLOGY — Most individuals experience some degree of homesickness when they leave familiar surroundings and travel to or enter a new environment [6,7]. Homesickness may be a significant source of distress and impairment for children and adolescents in the following settings [8-11]:

●Summer camp

●Boarding school

●College/university

●Athletic training programs

●Hospital admission

Homesickness also affects immigrants, international students, international employees, displaced persons, refugees, astronauts [12], and military personnel [13-21].

Prevalence — Estimates of the prevalence of homesickness vary depending upon the definition of homesickness, the population studied, the circumstances of separation, the type of measurement, and when the homesickness was assessed (eg, during a separation or retrospectively). As an example, estimates for homesickness among adolescent boarding school students range from 16 to 91 percent [10]. In the studies where homesickness was measured during the separation, the reported prevalence ranged from 83 to 95 percent [6,22].

Homesickness is equally prevalent among children attending summer camp and those who are hospitalized [9,23]. Younger children are at greater risk for homesickness than older children because they have relatively little previous experience away from home, not simply because of their age [6]. The prevalence and intensity are similar between males and females [4,22,24]. (See 'Risk factors' below.)

Approximately 20 percent of children who are away from home experience moderate to severe homesickness (defined by rating the average intensity of their homesickness at or above the midpoint of the rating scale used in the particular study) [4,6,22,23]. However, only 6 to 9 percent of children report homesickness that is associated with severe symptoms of depression and/or anxiety [4,6,9,22].

Homesickness in hospitalized children is more severe and less predictable than in children in less stressful environments. Across a variety of presenting problems, approximately 50 percent of hospitalized children ages 8 to 18 reported moderate to severe levels of homesickness [25]. The best predictors of homesickness were negative hospitalization attitudes and previous separations from home (eg, placement in foster care). In contrast to children in less stressful settings, homesickness in hospitalized children was not predicted by insecure attachment or low perceived control [25]. (See 'Risk factors' below.)

Data regarding the incidence and severity of homesickness in children with cognitive or developmental delay are lacking. However, it can be inferred that these children respond to separation from home and attachment objects in a manner consistent with their developmental age, separation attitudes, attachment style, aversion to change, social skills, and previous experiences away from home.

Among students at college or university, homesickness prevalence varies between 19 and 70 percent, again depending on the population, measurement methodology, and timing of assessment. A longitudinal study of 174 first-year university students in the central United States found that 94 percent reported some homesickness in their initial 10 weeks at school, thus confirming the near universality of missing home during a separation in a novel setting [26].

Risk factors — Risk factors for homesickness in both children and young adults include lack of experience with separation or the new environment, negative attitudes toward the separation or the environment, few social connections in the host environment, and little or no involvement in the decision-making process. In some cases, the demands of the host environment spark homesickness; in other cases, the host environment is not particularly challenging but the absence of loved ones and attachment objects sparks homesickness [27]. Insecure attachment to the primary caregiver is another reported risk factor [11], but this association is inconsistent [28].

These risk factors fall into four interrelated categories: experience, attitude, personality, and family.

Most of the information regarding these factors is derived from studies in adults, particularly the information about personality factors [29]. However, increasing information regarding the etiology of homesickness in children and adolescents is available. A theoretical model suggests a distinction between the feelings associated with the loss of home (eg, grief) and the feelings associated with adjustment to a novel environment (eg, social anxiety) [27].

●Experience factors – In studies of children at summer camps and boarding schools, the experience factors most predictive of homesickness include [23,30-33]:

•Little previous experience away from home (lack of practiced coping skills)

•Little or no previous experience at the camp or school (lack of familiarity, social support, and connections)

•Young age (lack of metacognitive and social skills)

Age is often a proxy for experience, which is the more powerful predictor of homesickness. An eight-year-old child with lots of experience away from home, as an example, is at lower risk to become homesick at summer camp than a 12-year-old with little experience away from home. Experience is probably most valuable when it motivates and refines coping strategies. (See 'Coping strategies' below.)

In contrast, previous experience away from home does not protect against homesickness in hospitalized children [25]. This observation suggests that the specific types of prior separation experiences shape expectations of future separations [34]. If early separations are negative experiences (as may be the case with foster placements and unplanned or traumatic hospitalizations), then expectations of future separations may be negative, predisposing to homesickness, as discussed below.

●Attitude factors – Beliefs that homesickness will be strong, coupled with negative first impressions, low expectations for the new environment, and poor social self-concept, are powerful predictors of homesickness [23,28]. Expectations of intense homesickness and negative experiences can become self-fulfilling prophecies. This was illustrated in a study of college freshmen in whom perceived absence of social support was a strong predictor of homesickness [31].

A child's attitudes regarding separation are largely shaped by their history of time spent away from home. In a study of males ages 8 to 16 who spent two weeks at camp, a combination of little previous experience away from home, low perceived control (discussed below), negative attitudes about the separation, and high expectations of homesickness accounted for nearly 70 percent of the variance in the intensity of self-reported homesickness [23].

●Personality factors – Insecure attachment to primary caregivers is the most frequent personality risk factor for homesickness [23], although this association is inconsistent [28]. In particular, children and adolescents with an anxious-ambivalent attachment style are likely to experience significant distress upon separation from home. Secure attachment, on the other hand, is associated with independence, a proclivity to explore, and social skills, all of which help young people settle in, connect, and adjust to a novel environment.

Two other personality factors that increase the risk of homesickness in children and adolescents (including older adolescents and young adults deployed in the military) are low perceived control and anxious or depressed feelings in the months before a separation [21,23] and during the initial days of a separation [33].

In adults, homesickness is predicted by low self-directedness, high harm avoidance, rigidity, neuroticism, low self-esteem, and a "fantasy" or "wishful thinking" coping style [29,35,36]. However, it is not clear whether these personality factors can be generalized to predict homesickness in children and adolescents. (See 'Coping strategies' below.)

●Family factors – The family factor most predictive of homesickness is low "decision control" [23,33]. A child who is forced by their caregivers to spend time away has little decision control and is more likely to feel homesick upon separation than a child who had a say in the separation's type and timing.

Other family factors that are weaker predictors of homesickness include caregivers who express anxiety or ambivalence about the separation (eg, "Have a great time at camp. I don't know what I'll do without you") and the presence of an unresolved negative life event [23]. In one study, parents' recollections of anxiety about their child spending a week in the host environment predicted homesickness for males, but not for females [33].

Conventional wisdom holds that a recent move, divorce, or similarly disruptive event might predispose a child to homesickness. However, this assumption is not supported by research [6]. It is plausible that if children have had a chance to process the thoughts and emotions associated with a recent negative life event, they are not at increased risk for homesickness.

CLINICAL FEATURES — Most children with homesickness present with withdrawn or depressed behaviors (eg, tearfulness, low motivation, loss of appetite) [4,6,37]. However, some children present atypically with externalizing behaviors (eg, anger, irritability, fighting, swearing, or destroying property) [4,6,7,22]. Other children and adolescents may present with somatic complaints.

Of the children who somaticize their distress, only a small percentage present to a medical provider during the separation. In one study of 1412 consecutive visits to a summer camp health center by children aged 6 to 15 years, only 2 percent were classified as "psychiatric" [38].

Severe homesickness is associated with social problems, behavior problems, significant symptoms of depression and anxiety, coping deficits, and feelings of helplessness [4,11,22,39-42].

In academic settings, homesickness among adolescents and young adults can be associated with nontraumatic ailments, such as stomach aches and headaches (some of which are undoubtedly somatization) [43-45], academic difficulties [26,36,46-49], absentmindedness [43,44,46,47], low self-esteem [47,50], social anxiety [31], loneliness [26,51], and/or obsessive thoughts and behaviors [43,44]. These factors are generally thought to be sequelae of homesickness, though some, such as social problems, can also be precipitants of homesickness.

CLINICAL COURSE — Longitudinal changes in the intensity of homesickness have been studied in children and adolescents attending summer camp or requiring hospitalization and in young adults attending university for the first time [4,6,9,22,26,52]. In these populations, two trajectories of homesickness have been described:

●The least homesick 80 percent of children and adolescents begin their stay away from home with a low level of homesickness and maintain that level throughout their time away. This appears to be the case for two-, four-, and seven-week stays at overnight camp, as well as for the initial 10-week term at university.

●The most homesick 20 percent of children and adolescents begin their stay with an elevated level of homesickness, and the intensity increases over the course of several weeks, decreasing somewhat just before reuniting with their caregivers. With preventive interventions, this trajectory can be altered significantly [9]. (See 'Prevention' below.)

The longitudinal course of homesickness for children and adolescents in other environments, such as refugee camps and foster homes, is unknown.

DIAGNOSIS — The most useful diagnostic tool is simply asking the question, "How homesick have you been feeling?" or "How much have feelings of missing home bothered you?" coupled with questions about functional impairment, such as behavioral withdrawal, insomnia, anhedonia, and loss of appetite. Asking direct questions about homesickness as part of a broader assessment of positive and negative moods, even on a daily basis, does not worsen symptoms of homesickness [4]. Quite the opposite: It puts adult caregivers, and sometimes peers, in a better, more informed position to help.

Homesickness may be comorbid with other behavioral, emotional, cognitive, and physical problems that warrant clinical attention. However, homesickness has a well-documented deleterious effect on adjustment, over and above pre-existing negative adjustment [26]. In addition, injuries or illnesses that occur during a separation may exacerbate or induce homesickness. Thus, it is important to exclude any contemporaneous but distinct physical ailments (eg, menstrual pain, influenza, otitis media), before attributing complaints to homesickness-related somatization.

PREVENTION

Overview — Primary care clinicians and caregivers can work together to prevent homesickness. Anticipatory guidance regarding homesickness can be provided during the following types of office visits:

●Physical examination before camp, boarding school, or college/university

●Establishment of care following a recent move (whether from a nearby town or from a different country or culture)

●Prehospitalization evaluation

Anticipatory guidance should emphasize homesickness as a normal feeling and include strategies for prevention as well as effective methods of coping. Talking about homesickness does not cause homesickness but helps children or adolescents to understand it and encourages them to utilize effective, effortful coping strategies while they are away [6,7].

Normalization — Separation from home is a normal developmental milestone, so an upcoming separation should be framed as a positive developmental experience, especially in the case of a planned separation. It is important for children and adolescents to know they are likely to miss certain aspects of home when they are away. Such feelings are normal and indicate there are things about home they love and to which they are attached. Qualitative analyses have confirmed that, for most people, the familiar concept of "home" is associated with a comfortable and safe environment [53,54].

Planned separations — For planned separations (eg, boarding school, overnight camp, university), the primary care provider can:

●Encourage families to use evidence-based prevention programs that teach children and caregivers how to prepare for planned separations and how to cope in situ with strong feelings of missing home [9].

●Help caregivers assess their child's readiness to spend time away from home. Knowing when the time is right for a planned separation is the cornerstone of homesickness prevention [55]. If conversations with a caregiver or child suggest great anxiety about a planned separation, the caregivers may want to consider postponing the separation until they and child have prepared for it together and are thereby more comfortable with it. The transmission of caregiver separation anxiety to children is well documented [33,56].

●Advise young people to use social media in moderation and in ways that studies have shown to be helpful. Specifically, ask the organizers of the new environment (eg, college/university, boarding school, summer camp) whether they use a designated online platform to help participants make friends with other participants [57]. Encourage international students to use social media to cultivate connections with host-country students [58].

●Ask about previous separations; little previous experience away from home or with the particular new environment is predictive of homesickness. (See 'Risk factors' above.)

●Encourage practice time away from home, and encourage caregivers to use the prevention strategies described briefly below and in greater detail in the table (table 1) [1]. (The table can be printed and given to the caregivers as a reference.)

•Involve the child in the decision to spend time away from home

•Educate the child regarding the normalcy of homesickness

•Provide explicit instructions for coping, using both cognitive and behavioral strategies

•Explain that coping is a process that requires sustained effort over a period of multiple days

•Arrange for practice time away from home

•Practice letter writing with the child whenever the new environment does not permit electronic communication

•Work with the child to learn about the new environment via printed or online media or from peers with previous experience living in the host environment

•Help the child get to know at least one person in the new environment

•Teach friendship skills and encourage the child to make new friends in the new environment

•Teach assertiveness skills and encourage the child to seek the support of trusted adults in the new environment

•Refrain from expressing anxious or ambivalent feelings about time away from home; share these feelings with an adult peer instead

•Maintain predictability and perspective about the time away

●Assess the child's coping skills. (See 'Coping strategies' below.)

●Strongly dissuade caregivers from making pick-up deals. (See 'Pick-up deals' below.)

●Help caregivers select a school or camp that is well matched to their child's interests, abilities, and developmental needs [59].

●Be sure the caregivers have a plan for keeping in touch and they understand the school's or camp's policies regarding phone calls, videoconferences, emails, and in-person visits.

●Help educate surrogate caregivers (eg, camp counselors, resident advisors) about the symptoms of homesickness and the most effective treatments and coping strategies. (See 'Management' below.)

Hospitalization — The primary care provider's role in the prevention and treatment of homesickness in hospitalized children depends upon whether the hospitalization is planned.

For unplanned hospitalizations, the best approach may be to educate caregivers about the normalcy of adjustment difficulties encountered during hospitalizations, including homesickness [25]. The clinician can then coach the caregivers (table 2) and hospital staff (table 3) regarding ways to bolster the child's coping skills [1]. (The homesickness prevention table can be printed and given to caregivers as a reference.) Frequent, predictable contact between children and their primary caregivers is of paramount importance during any hospitalization.

For planned hospitalizations, anticipatory guidance should focus on creating positive attitudes about the hospitalization. Negative separation attitudes are a strong predictor of homesickness [23,33]. Thus, it is essential that caregivers and clinicians convey positive expectations about the helpful outcomes of the hospitalization. (See 'Risk factors' above.)

Anecdotal evidence also suggests that orienting children to the hospital unit, to various medical procedures, and to the staff who will be caring for them reduces anxiety and minimizes homesickness. Hospitalized persons can be easily disoriented. Although it may seem trivial, whiteboards that list the names of providers and providers who restate their names and roles at each visit can help to reorient them. (See 'Risk factors' above.)

Special populations

Displaced families — For displaced families, it is helpful for the primary care provider to take the time to understand the circumstances of the recent move, how it affected the family members, what the child misses most about where they used to live, and what, if any, grief-inducing traumatic losses have occurred.

Homesickness in displaced families is ameliorated by settling into and becoming a part of the new community [14]. Caregivers and children alike benefit from social support, a sense of purpose (eg, work, school, sports), and feelings of security [41,60]. Anecdotal evidence also suggests that introducing personally important elements of the culture of origin, such as favorite snacks and traditions, can attenuate homesickness intensity.

Pediatric health care providers can be instrumental in helping displaced families to access the social, educational, cultural, and vocational opportunities in the new community. Connecting a newly displaced family with an established family of the same ethnicity, religion, or country of origin can be particularly helpful. Ensuring that displaced families have easy access to necessities, perhaps in collaboration with a social worker, also reduces distress in parents and their children.

Children with special health care needs — For children with special mental, physical, or emotional needs, the primary care provider can help ensure the school or camp has the appropriate resources in place to support and care for the child. Elective interruptions in pharmacologic therapy for behavioral or psychiatric disorders (eg, "drug holidays") should be avoided during transitions to the new environment but may be considered after a month or more of positive adjustment in the new setting [59].

MANAGEMENT

General guidelines — Management of homesickness involves the following strategies [9,11,32,53,61]:

●Normalizing homesickness, recognizing that people who lack compassion for their own distress actually feel more homesick [62] (see 'Normalization' above)

●Coaching children and adolescents on effective ways to cope, recognizing that feelings of homesickness often diminish people's inclination to seek social support (see 'Coping strategies' below)

●Working on building new social connections, recognizing that moderate social support from home can be helpful, but excessive contact with home can eclipse opportunities to make friends in the new place [28]

●Helping children and adolescents maintain perspective on the finite duration of the separation

●Involving children and adolescents with the new environment in ways that leverage their unique skills and character strengths, and foster their connections and commitment to the new place and new people

●Encouraging children and adolescents who have strong religious beliefs to continue routine prayer or meditation practices [63]

Summer camp stays

Coping strategies — Studies in children (aged 8 to 16 years) who spent two weeks at overnight summer camp have revealed several strategies that are effective for coping with homesickness [39,40]. These include:

●Distraction and social connection (eg, doing something fun, like playing with friends, to forget about homesick feelings)

●Contact with home (eg, writing a letter or looking at a family picture to feel closer to home)

●Social support (eg, going to see someone whom they can talk with to help them feel better)

●Social connection (eg, reaching out to make new peer friends)

●Optimism (eg, thinking about good things, like activities and friends, to feel better)

●Perspective (remembering that the time away is finite, to make the time go by faster)

●Cognitive avoidance (trying not to think about home and loved ones to forget about feelings of missing home)

●Vicarious social support (thinking about what loved ones would say to help)

Males and females report using these strategies with nearly equal frequency, except for social support, which females report using more often than males [39].

Additional studies have identified strategies that are not helpful (eg, relinquished control, fantasy, delinquent behavior, escape) [35,39,40]. Few children respond to the stress of separation from home with these approaches, but some, particularly males, may try. The ineffective strategies are mentioned here so that caregivers can steer children away from them and toward something more helpful.

●Relinquished control (eg, doing nothing because of a belief that nothing would help make things better)

●Fantasy or wishful thinking (eg, wishing that camp or school would end tomorrow)

●Doing something forbidden or mean to get sent home (aggressive or delinquent behavior)

●Escape (eg, trying to get home earlier than planned)

Contact with home — Professional opinions are mixed and research is scant regarding phone calls and email contact during planned separations. The kind and frequency of child-caregiver contact should ultimately be dictated by the goals of the separation.

At summer camps, for example, anecdotal evidence suggests that phone calls and text messages exacerbate homesickness during stays of less than four weeks. Such real-time correspondence also erodes the burgeoning independence that camps and trips are designed to nurture [64]. Thus, caregivers should be strongly discouraged from insisting they talk with their homesick child during a short stay away. It is likely that such contact will increase the distress for both parties.

Handwritten letters may be the best way to maintain contact with home. Letters lack the emotionally evocative quality of a phone call or videoconference, and they require narrative reflection, which promotes understanding of one's experience [65]. Such reflection may even serve a therapeutic function, as does keeping a journal.

During longer separations (eg, camp stays longer than four weeks, boarding school, college/university), phone calls, texts, and emails, after an initial two weeks of settling in without such contact, do not seem to interfere with the child or adolescent's enjoyment of the experience and may decrease homesickness intensity [32], despite their evocative nature [14] and the inherent risk that too much contact with home hinders new social connections. However, in one longitudinal study of homesickness in first-year university students, videoconferencing was associated with higher self-reported homesickness intensity [66].

Pick-up deals — Under no circumstances of planned, recreational separations from home should caregivers make a "pick-up deal" with their child [1,59,67]. Promising, "If you don't like it, I'll come pick you up," reduces the child's likelihood of success for several reasons.

●The subtext of such deals is, "I have so little confidence in your ability to cope with this normal response to separation that I believe the only solution is for me to rescue you." Such expressions of anxiety and doubt contradict the recommended expressions of optimism and confidence outlined in the prevention strategies (table 1) [1].

●Such deals plant the seeds of homesickness by giving young people the expectation that they will not like the new place. Negative separation attitudes are powerful predictors of homesickness [23].

●Such deals prevent the development of effective coping by pointing young people toward an escape route.

●Such deals paralyze surrogate caregivers who, after enthusiastic support and coaching, may be faced with a child who says, "My parents said that if I didn't like it here, they would come to get me." Caregivers are then faced with two equally unsatisfactory choices:

•Fulfill their promise, pick the child up, and deprive them of a wonderful opportunity to grow and develop

•Renege on their promise and suffer an erosion of trust in their relationship with the child

Hospital stays — Research examining the association between contact with home and adjustment in hospitalized children is scarce. A review of these studies suggests that the quality, rather than the quantity, of child-caregiver contact is associated with social and emotional adjustment [25].

Because the goal of hospitalization is good health, rather than increased self-reliance and social maturation, a different approach to child-caregiver contact is warranted than for children at camp. Whereas minimal contact is encouraged during a stay at camp, maximal contact (both in-person and electronic) is appropriate for children hospitalized with medical problems. During psychiatric hospitalizations, staff can advise caregivers on the appropriate quality and quantity of child-caregiver contact. Indeed, this contact may be an integral part of treatment.

University and boarding school stays — Research about homesickness at boarding school or university has focused on new students, especially international students and students with little prior experience away from home, because this group of students are at greatest risk for intense homesickness. A survey of first-year university students suggests that students who perceive support from the school feel less homesick than those who feel that the institution is unsupportive [68]. Another study suggested that students who formed close ties to school across the first term were less homesick than those who primarily maintained close ties to home [69].

Schools can show their support for new students by providing factual information (eg, schedules, maps, events) during orientation and induction (low perceived control is associated with homesickness in first-year university students), organizing social events (eg, activities, parties, concerts) that help the students make friends [70], and familiarizing students with the mental health resources available on and off campus [71].

In addition to the beneficial effects of a supportive institution and social connections, other comforts (eg, an animal companion) and community integration (eg, volunteer service) have been shown to reduce homesickness intensity in first-year university students [72,73]. Religiousness also may moderate homesickness intensity for mildly homesick first-year students but not for severely homesick students [63].

Social networking, which provides superficial contact to both old and new friends, as well as to family, appears not to mitigate homesickness intensity [74], except in the case of international students who use social networking to nurture host-country friends [58]. Intentionally connecting new international students with domestic students is an important part of a school's early-term homesickness prevention program. In a survey of international students, having host-country friends (and not exclusively home-country friends) was associated with decreased homesickness [75]. In addition, smartphone applications that help international or domestic students connect with other students with similar interests may be helpful [57].

The coronavirus disease 2019 (COVID-19) pandemic was a surrogate for research on the global effectiveness of social networks, smartphone applications, and videoconferencing as a substitute for face-to-face interactions. They are not effective substitutes, as the precipitous rise in youth mental health problems, despite vastly increased time spent online, makes clear [76].

Schools should also try to create inclusive communities where discrimination is minimized, social support is maximized, and cultural and linguistic welcoming are ample because acculturation stress – the mental and emotional challenges of adapting to a new culture – can exacerbate homesickness [77,78].

RESOURCES FOR FAMILIES — Resources for families are listed in the table (table 4) [1].

SUMMARY AND RECOMMENDATIONS

●Definitions – Homesickness is defined as the distress and functional impairment caused by an actual or anticipated separation from home. (See 'Definitions' above.)

●Risk factors – Risk factors for homesickness include lack of experience with separation or the new environment, negative attitudes toward the separation or the environment, insecure attachment to the primary caregiver, and little or no involvement in the decision-making process. (See 'Risk factors' above.)

●Clinical features – Most children with homesickness present with withdrawn or depressed behaviors. However, some present with somatic complaints or externalizing behaviors (eg, anger, irritability, fighting, swearing, or destroying property). (See 'Clinical features' above.)

●Clinical course – Moderate/severe homesickness typically does not improve spontaneously but can be largely prevented. (See 'Clinical course' above.)

●Diagnosis – The diagnosis of homesickness is made by asking the question, "How homesick have you been feeling?" (See 'Diagnosis' above.)

●Prevention – Primary care clinicians and caregivers can work together to prevent homesickness during planned separations (table 1) or hospitalizations (table 2). (See 'Planned separations' above and 'Hospitalization' above.)

●Management – Management of homesickness involves normalizing homesickness, teaching effective coping strategies, building social connections, helping children maintain perspective, and fostering commitment to the new environment. (See 'General guidelines' above.)

•Effective coping strategies include distraction, social connection, asynchronous contact with home (eg, writing a letter, looking at a photograph), social support, acculturation, optimism, perspective, cognitive avoidance, and vicarious social support. (See 'Coping strategies' above.)

•Coping strategies that are ineffective include relinquished control, fantasy, delinquent behavior, and escape. (See 'Coping strategies' above.)

•The kind and frequency of child-caregiver contact during separation depends upon the goals of the separation. (See 'Contact with home' above.)

•We strongly discourage caregivers from making "pick-up deals" with their children during planned, recreational separations. (See 'Pick-up deals' above.)