Anxiety disorders in children and adolescents — formative SAQs

SAQ 1 (10 marks)

A 9-year-old boy has a four-month history of abdominal pain and nausea on weekday mornings that resolve if he stays home. He fears something terrible will happen to his mother while he is at school and checks on her repeatedly. He sleeps poorly the night before school and clings at the gate. At weekends he is bright and energetic. There are no medical red flags, no bullying, and no suicidal ideation. Mother has a history of anxiety. ^{[2] [5]}

1. State the most likely diagnosis and three features that distinguish it from normal developmental separation fear. (3) ^{[2] [5]}
2. Outline a multi-informant assessment including validated scales and the investigations you would and would not order. (3) ^{[2] [5] [6] [7]}
3. Describe first-line management, including the active ingredient of the psychological therapy and the role of an SSRI at this stage. (4) ^{[1] [3]}

Model answer — SAQ 1

(1) Diagnosis and discriminators (3). Most likely separation anxiety disorder (DSM-5: developmentally inappropriate and excessive fear concerning separation from attachment figures, at least 4 weeks, causing impairment). Three distinguishing features: persistence beyond the developmental window (4 months, age 9, not a toddler); functional impairment (sleep disturbance, school avoidance, repeated checking); and the fear is out of proportion (catastrophic belief that mother will be harmed). Normal developmental separation fear is age-appropriate, transient and resolves with reassurance. ^{[2] [5]}

(2) Multi-informant assessment (3). Separate interviews of the child and caregivers plus school collateral, because children under-report internalising symptoms. History: onset/course, somatic pattern by day of week, fear map, impairment, sleep, bullying, trauma, family psychiatric history, developmental history. Structured suicide/self-harm risk assessment (anxiety does not protect against suicide). Validated scales: SCARED (child and parent versions) and/or Spence Children's Anxiety Scale or RCADS for dimensional severity and tracking. Investigations: targeted medical workup only if red flags (none here) — no routine bloods or brain imaging; avoid serial investigations that medicalise avoidance. Document comorbidities (depression, ADHD, ASD). ^{[2] [5] [6] [7]}

(3) Management (4). Stepped care, starting with psychoeducation (explain the worry cycle and that the family did not cause it but accommodation can maintain it). Exposure-based CBT is first-line: the active ingredient is graded in vivo exposure (separation steps, school return hierarchy), plus cognitive restructuring of catastrophic separation beliefs, parent sessions to reduce accommodation and excessive reassurance, and contingency management. Cochrane 2020 supports CBT for childhood anxiety. An SSRI is not first-line here — he has no comorbid moderate-severe depression, CBT has not failed, and impairment is not yet severe. Reserve SSRI (sertraline 25 mg oral daily start) for inadequate response, severe impairment, or comorbid depression. Avoid chronic benzodiazepines. ^{[1] [3]}