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]

SAQ 2 (10 marks)

A 15-year-old girl with social and generalised anxiety has had a partial response to 14 sessions of exposure-based CBT. She remains markedly impaired: she avoids the canteen and oral presentations, has daily headaches and muscle tension, and has missed 30% of school days this term. She describes two weeks of low mood and intermittent passive thoughts that she "would be better off not here" but no plan or intent. Parents ask whether she should start medication. [1] [2] [4]

1. List the immediate priorities before adjusting the anxiety treatment plan. (3) [2] [4]
2. Outline the SSRI evidence and an appropriate practical start, with monitoring. (4) [1] [2] [4]
3. Explain why chronic benzodiazepines are a poor choice and what the disposition should be. (3) [2]

Model answer — SAQ 2

(1) Immediate priorities (3). The passive death wishes require a structured suicide and self-harm risk assessment and safety planning before any routine anxiety plan — comorbid depression raises the risk priority above the anxiety alone. Screen medical red flags for somatic symptoms. Reassess whether CBT dose and exposure adherence were adequate (was the hierarchy actually climbed?). Reassess for comorbid major depression, ADHD, substance use and safeguarding. Involve carers and specialist CAMHS given the partial response and emerging mood symptoms. [2] [4]

(2) SSRI evidence and practical start (4). An SSRI is now indicated — moderate-severe impairment, partial CBT non-response, and comorbid depressive symptoms. CAMS (Walkup 2008): combination CBT plus sertraline gave the highest response (~80.7%); sertraline monotherapy (~61%) and CBT (~55%) each beat placebo. Sertraline is the most evidence-based first choice. Practical start: sertraline 25 mg oral daily, titrate gradually toward clinical response; continue CBT in combination (combination = best evidence). Counsel the black-box suicidality risk (Bridge 2007 meta-analysis: small absolute increase in suicidal ideation and behaviour signals versus placebo) — discuss risk-benefit with carer and young person, and review within 1 to 2 weeks of starting and after each dose increase. Monitor for activation, gastrointestinal effects, sleep change and headache. [1] [2] [4]

(3) Benzodiazepines and disposition (3). Chronic benzodiazepines are a poor answer for paediatric anxiety maintenance: dependence risk, cognitive adverse effects, and weak long-term evidence. Reserve them, if at all, for short-term acute crises under specialist guidance. Disposition: combination CBT plus SSRI in specialist CAMHS given the partial response and comorbid depression; re-measure with a validated scale; safety-net for escalating suicide risk and review the diagnosis (rule out evolving bipolar or substance-related mood change). [2]