Separation anxiety disorder — school refusal and adult under-recognition (MEQ)

(i) Assessment priorities. Assess child and mother as linked but separate patients. Child: map eight SeAD domains (distress on separation, worry about harm/loss, school refusal, inability to be alone, sleep-away refusal, nightmares, physical symptoms); duration (here continuous months, exceeds ≥4-week youth threshold); onset after father's hospitalisation; school days missed; medical red flags for abdominal pain; bullying/learning screen; MSE; risk of self-harm rare but hopelessness possible; collateral from school. Mother: adult SeAD domains with partner as attachment figure; duration typically ≥6 months (here 2 years); panic only when alone (content matters); depression screen and full suicide assessment for passive death wishes (ideation, intent, plan, means, protective factors); substances; accommodation behaviours that maintain the child's avoidance; her own treatment history. Capacity and child-protection vigilance if care is severely compromised. Scales: youth anxiety screen, adult SeAD severity concepts, PHQ-9/GAD-7, separation SUDs hierarchies.[1][2][5][6]

(ii) Working diagnoses and differentials. Child: separation anxiety disorder with school refusal and sleep proximity seeking after attachment threat (father's illness); rule out primary medical GI disease, social anxiety as sole driver, autism change intolerance alone, and depression. Mother: adult separation anxiety disorder with partner-focused checking and alone-intolerance; depressive episode symptoms with passive suicidal ideation needing full MDD review; differential panic disorder (attacks context-bound to aloneness/separation), GAD (if multi-domain worry emerges), dependent personality (only if pervasive enduring pattern beyond separation syndrome). Intergenerational accommodation is a shared maintaining formulation, not a single fused diagnosis.[2][5]

(iii) Psychological plans. Child: family-based CBT for SeAD — psychoeducation, graded school return hierarchy, sleep-alone steps, cognitive work on catastrophe beliefs, reduce parental accommodation (bed-sharing, permitting non-attendance). Mother: graded exposure to being alone and to partner travel with response prevention for location-checking; couple session to align plans so mother does not model panic at every separation. Parallel education liaison for attendance targets. Do not use harsh unplanned extinction or indefinite home schooling without a therapeutic goal.[3][6]

(iv) Medication. Psychological first-line; add SSRI for moderate-severe symptoms or partial response. Child (CAMS-informed): sertraline 25 mg orally once daily, titrate under specialist/CAMHS supervision toward effective tolerated range commonly 50–200 mg/day; monitor activation, suicidality, sleep, GI effects; combination CBT + sertraline often superior to either alone in childhood anxiety trials. Fluoxetine alternative with childhood anxiety RCT support (typical start 10 mg orally daily with titration and same monitoring). Mother: if indicated, sertraline 25–50 mg orally daily titrating toward 50–200 mg/day, or escitalopram 5–10 mg toward 10–20 mg/day, early review for activation/suicide risk given PHQ-9 and passive death wishes; avoid chronic benzodiazepine monotherapy.[4][6]

(v) Disposition and adult under-recognition. Child: CAMHS/psychology priority with school plan and GP shared care. Mother: adult mental health or primary care psychology; safety plan for passive suicidal ideation; increase follow-up frequency after any antidepressant start. Explicitly name that adult SeAD remains under-recognised — do not collapse mother's presentation into "worried mum" or dependent personality without criteria. Step-up if attendance fails, risk escalates, or severe parental illness impairs care.[1][5][6]