Separation Anxiety Disorder Case Study Analysis

Separation Anxiety Disorder Case Study Analysis

The case presented is of a seven-year-old girl, Ava, who was referred for care by her PCP. She is the second born in a middle-class family. Ava met all of her developmental milestones. She undertook her nursery and kindergarten education at a private nursery school where personal attenuation was given to each child at four. Her mother became sick with lupus and could not afford the tuition fees when she was in kindergarten. This prompted her to transfer to a public school in first grade at six. For two weeks, she refused to go to school and missed six school days. She also began to brush her hair routinely before bed, insists on brushing each side with an even number of strokes, has her mother tucking in her bed on the right and her dad on the left side each night, and becomes tearful and upset if this routine is not followed. She remains awake and worries all night about the school and asks questions about the school, its environment, the teachers, and other students. At the start of the day, she cries, pulls her hair, chews holes in her shirt, digs her face, punches the walls, and screams. She also experiences headaches, vomiting, and stomach aches. She has since been gloomy, frequently worries about her mother’s health and even dreams of her funeral, and stopped reading for fun. Ava’s family history revealed that her mother has a history of panic disorder, her father has a history of ADHD management, and her cousin was diagnosed with Asperger’s syndrome. A physical exam revealed no physical abnormalities.

The Provisional Diagnosis and Possible Differentials

The provisional diagnosis is separation anxiety disorder. The child manifested symptoms that are consistent with those of separation anxiety disorder as detailed in DSM-V. Additionally, the family history added weight to this diagnosis. Schiele et al. (2020) note that separation anxiety disorder is twice as high in children with close relatives having panic disorders. In this case, Ava’s mother had a history of panic disorder. The differentials in this case include generalized anxiety disorder, panic disorder, specific phobia, and social anxiety disorder.

Justification with the DSM-V Criteria

DSM-V outlines the diagnostic criteria for anxiety disorders. Per the DSM-V, a positive diagnosis of separation anxiety disorder is made when a child develops appropriate and excessive anxiety when separated from an individual or an environment to which they are attached (Patel & Bryant, 2021). This is evidenced by the recurrence of excessive distress with anticipated or actual separation from home or the attachment figure, persistent and pervasive worry of losing the attachment figure, refusal to go out, refusal to sleep, repeated dreams or nightmares about separation, and repeated physical symptoms or verbalization of symptoms such as headache, stomachache when the separation occurs. Three of these symptoms must have occurred for the last four weeks; the symptoms must be causing disturbances in an individual’s life and cannot be explained by any other psychiatric illness.

Ava presented with the majority of these manifestations. She refused to go to school, developed persistent and pervasive worry about losing her mother, dreamed of her mother’s funeral, manifested physical symptoms of vomiting, headache, and stomach at the time of separation, developed acute distress at the thought of going to school, and insisted that her attachment figures tucked her to her bed before sleeping. These manifestations are consistent with those described in the DSM-V. The child also met the criteria for duration, as the symptoms had been present for the past four weeks. Her history and physical and subjective findings were also not suggestive of any other psychiatric illness.

Diagnosis

At the time of her presentation, Ava was six years of age. Separation anxiety disorder (SAD) is a common childhood disorder and can be diagnosed in a six-year-old child. Identification of SAD is based solely on evaluation. Symptoms and manifestations are highly suggestive of this diagnosis.

Psychiatric Scales or Assessment Tools

Multiple screening tools are valuable in the comprehensive assessment of anxiety disorders. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) is one the most effective and commonly used assessment tools for anxiety disorders. This tool can be used on Ava. Both the parents and the child can use the SCARED tool. It is a self-report tool that assesses the presence or absence of anxiety symptoms. Separation Anxiety Avoidance Inventory (SAAI) can also used by the child and the parents. It is more specific to SAD. Other assessment tools that can be used include the Children’s Separation Anxiety Scale (CSAS), the Anxiety Disorder Interview Schedule (ADIS), and the Pediatric Anxiety Rating Scale (PARS). These tools are valuable in assessing the severity of the symptoms and making a diagnosis and can be used as part of the comprehensive assessment and diagnostic framework.

Treatment Plan

A comprehensive treatment plan for children with SAD utilizes both pharmacotherapeutic and non-pharmacotherapeutic interventions. Medications used to manage SAD are serotonin reuptake inhibitors (SSRIs). Examples that are effective and safe to use in children include fluoxetine and escitalopram. These medications improve anxiety symptoms and can help calm the child (Amray et al., 2019). In this case, the target symptoms are excessive worry and inability to sleep. These medications target the serotonin receptors. They inhibit the reuptake of serotonin, thereby enhancing serotonin activity. The possible psychiatric and system effects include sedation, dizziness, lethargy, agitation in some patients, blurred vision, and GI distress. Despite their tolerability and excellent safety profile, SSRIs increase suicidality risks. This may be a parental concern. As a point of parental education at the point of care, parents should be notified of this concern and told to monitor their children for suicidal ideation and thoughts.

The School-Based Treatment Plan

The school-based treatment plan for Ava will utilize the Baltimore Child Anxiety Treatment Study in the Schools (BCATSS) program. This is a CBT-based intervention tailored for children with anxiety spectrum disorders. It can be implemented individually and in groups. It includes ten 45-minute sessions in which the child’s parents are involved in at least three of the sessions. This program is effective in reducing anxiety symptoms and improving independence (Amray et al., 2019). Thus, it can be applied to the child in this case.

Implications for Families

SAD has profound effects on the individual sufferers and their families. It severely affects the quality of life of children and adolescents with the disorder. It also diminishes their functionality across areas such as school, close relationships, and social interactions. SAD can also lead to poor mental and physical health outcomes as somatic complaints, inability to sleep, and excessive worry usually accompany the disorder. To the family, it may result in psychological distress. The thought that a close member is suffering may cause stress to the family members. Additionally, the family may have to handle the cost of treating the child.

The Role of Ava’s Mother’s Health in Ava’s Diagnosis

Ava’s mother has lupus. The prospects of suffering and death can result in feelings of worry, sadness, and helplessness in close family members. It may also compound underlying anxiety disorders and depression. This may be the case in Ava’s life. The thought of losing her mother may have been worsening her illness. SAD also has a genetic predilection. Schiele et al. (2020) note that the propensity to develop SAD and other anxiety disorders is increased in children with family members having any anxiety disorder. Ava’s disorder may have a genetic imprint. In this regard, cognitive behavioural therapy can help Ava and her family work through their problems and have some control of the situation.

Resources for Patients/Families

Several community resources exist for persons with anxiety spectrum disorders. These include the Academy of Cognitive and Behavioral Therapies, the American Psychiatric Association, the American Psychological Association, and the Andrew Kukes Foundation for Social Anxiety. These resources are available online. They are valuable in providing information on anxiety disorders and the available therapeutic interventions.

A Point of Worry in This Case

A point of worry in the comprehensive management of Ava is relapse. Childhood anxiety disorders often have a good prognosis if treated effectively. A four-year longitudinal study by Phillips et al. (2020) noted that relapse rates are as high as 48% in children if not managed properly. In this case, the child may fail to attain remission if adequate treatment is not given to her. In the presence of other troubles in her life, such as having an ailing mother and the diminishing financial capabilities of the family, she risks having a chronic illness.

References

Amray, A. N., Munir, K., Jahan, N., Motiwala, F., & Naveed, S. (2019). Psychopharmacology of pediatric anxiety disorders: A narrative review. Cureus. https://doi.org/10.7759/cureus.5487

Patel, A. K., & Bryant, B. (2021). Separation anxiety disorder. JAMA, 326(18), 1880. https://doi.org/10.1001/jama.2021.17269

Phillips, K. E., Norris, L. A., & Kendall, P. C. (2020). Separation anxiety symptom profiles and parental accommodation across pediatric anxiety disorders. Child Psychiatry & Human Development, 51(3), 377–389. https://doi.org/10.1007/s10578-019-00949-7

Schiele, M. A., Bandelow, B., Baldwin, D. S., Pini, S., & Domschke, K. (2020). A neurobiological framework of separation anxiety and related phenotypes. European Neuropsychopharmacology, 33, 45–57. https://doi.org/10.1016/

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For your assignment, write a paper that addresses the following prompts using evidence-based references to support your answers:

Summarize the case.

What is your provisional diagnosis, as well as the possible differentials?

Justify your answer with DSM-5 criteria (be short, brief and to the point).

Is Ava too young to diagnose, or is there a basis for early identification and intervention?

What psychiatric scales or assessment tools might you use with this patient? With the parents? List and describe briefly.

What would be your treatment plan for medications, if any? If you do choose to offer medication as part of the treatment plan, please address the following medication issues:

Target symptoms

Receptors affected

Psychiatric and system effects

Possible parental concerns

What would be your school-based treatment plan, if any?

What would be the implications for the families of children and adolescents with these diagnostic pictures?

How does the mother’s health play into the picture of Ava’s diagnosis? What type of therapy would you recommend for Ava (and her family) to work through her issues?

Identify resources for patients/families with this diagnosis in the form of community groups, web-sites, advocacy, as well as treatment resources available in your service area.

What are you worried about (if anything)? Consider this question in terms of treatment, assessment, alliance, compliance, effectiveness, safety, and other factors.