Running head: CLINICAL CASE STUDY 1

Clinical Case Study

6-Year-Old African American female with Separation Anxiety Disorder
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Chief of Complaint: “She is afraid to go to school.”

HISTORY OF PRESENT ILLNESS (HPI):
Patient presents as a new patient with mother to establish care. Mother states patient was referred
by PCP for further evaluation. At age four, patient was in nursery school and appeared to
function normally except during the first month when she had difficulty when her father would
drop her off at school. The nursery school was a small private school with a lot of personal
attention given to each child. Although shy, she made friends and liked going to nursery school
after she became adjusted to the new setting. Her parents liked the school so much that they
decided to keep Katy in kindergarten at this school with her same teachers and friends. However,
tuition at the school became a problem after Katy’s mother became sick with lupus and was
unable to work. For the last two weeks, patient has refused to go to school and has missed six
school days. Mother reports patient is awake almost all night worrying about going to school. As
the start of the school day approaches, she cries and screams that she cannot go, chews holes in
her shirt, pulls her hair, digs at her face, punches the wall, throws herself on the floor, as well as
experiences headaches, stomachaches, and vomiting. Over the past two weeks, she has become
gloomy, has stopped reading for fun, and frequently worries about her mother's Lupus and that
she may die. In addition, she is phobic of dogs, avoids speaking and writing in public, and wets
the bed every night.
PAST PSYCHIATRIC HISTORY:
No history
SUBSTANCE USE HISTORY:
No history
PAST MEDICAL/SURGICAL HISTORY:
No history
CURRENT MEDICATIONS:
None
ALLERGIES:
No known drug allergies
FAMILY PSYCHIATRIC HISTORY:
Mother- h/o panic disorder
Father- h/o ADHD and was treated as a child
Cousin- Asperger’s syndrome.
SOCIAL HISTORY:
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Patient 6 y.o. AA female, the second of two children of a middle-class family living in a
suburban area of a northwest city. Has one sister that is two years older than her. Her mother’s
pregnancy was normal and patient’s birth was normal. Had colic the first three months, cried
extensively and was difficult to comfort. After three months she became passive and cried very
little with comfort from her mother. Growth and development appeared to be normal, meeting all
the developmental milestones her first three years. She interacts normally with her sister and
parents, except that she would become tearful and anxious when her parents would get a
babysitter. Mother denies history of sexual or physical abuse. Religion is Baptist. Enjoy drawing
and reading.
REVIEW OF SYSTEMS:
HEENT: Reports headaches; Denies eye tearing or pain; Denies no change in hearing or no
pain; Denies history of nose bleeds, obstruction, or discharge; Denies difficulty swallowing,
soreness, or swelling.
Mouth: Denies dental cavities, bleeding of the gums, or use of dentures.
Neck/Lymphatics: Denies any stiffness, pain, or tenderness; Denies any swollen lymph nodes or
mass.
Chest/Lungs: Denies any SOB, wheezing, or cough.
Heart: Denies chest pains or heart palpitations; Denies any history of syncope episodes.
GI/Abdomen: Reports stomachaches and vomiting.
GU/Urinary: No change in urine; Denies urinary urgency, hesitancy, or frequency; Denies
dysuria.
Genital: Denies any discomfort or history of STIs.
Hematological: Denies any abnormal bleeding or unexplained bruising.
Endocrine: Denies any swelling in the neck area; Denies any symptoms related to diabetes or
thyroid issues.
Skin, Hair, Nails: Reports sores on facial area; Denies any change in nails or hair.
Musculoskeletal: Denies any muscle or joint pain; Denies any numbness or tingling in upper or
lower extremities; Denies limited range of motion.
Neurologic: Denies any weakness or tremors; Denies change in LOC or history of seizures.
PHYSICAL EXAMINATION:
General: Miss. K. is 3ft 6in: 50 pounds; BMI-19.9
Vital Signs: B/P- 99/64; HR- 101; RR- 20; T- 98.9
MENTAL STATUS AND ASSESSMENT:
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Miss K. is a 6 y.o. AA female physically the patient appeared age appropriate of stated age with
normal gait, obese and with poor eye contact. Emotionally the patient appeared anxious and
uncooperative. Attitude in the interview consisted of withdrawn. Observed behaviors included
psychomotor agitation and restlessness. The patient presented with soft slow speech, a normal
speaking rate and normal pitch. Patient became very nervous and anxious when asked a question
during exam. Mood/ affect was withdrawn and inattentive. The patient's thought process was
racing and his thought content consisted of suicidal ideations. There were no signs of
hallucinations or misperceptions on exam. Judgement was normal. The patient appears to be
aware of their present condition. Cognitive functioning and fund of knowledge was intact and
age appropriate. Short- and long-term memory were intact. The patient was oriented to the
correct time, place, person. There was impaired attention/concentration seen on exam. The
patient had normal recent and remote memory. Fund of knowledge included normal awareness of
current and past events. The patient had intact verbal intelligence.
Diagnostics to Consider:
Baseline Labs: Collecting baseline labs would help to rule out any medical conditions that could
possibly causing symptoms and/or help to establish baseline prior to initiating pharmacotherapy.
Collect the following labs as a baseline: CBC, CMP, Lipid panel, Hgb A1C, LFTs, Thyroid
panel, lead blood test, Vitamin B12/Folate, PT/PTT, UA, and UDS.
Referrals: Request medical records for referring Pediatrician; Psychologist for psychological
evaluations for additional testing to r/o other disorders.
Differential Diagnosis/ DSM-V criteria:
- Separation Anxiety Disorder- Youth with SAD avoid separation situations (e.g.,
refusing to attend school, sleep alone, or be left with a babysitter), worry about the safety
of self and/or attachment figures, and experience physical symptoms of anxiety (e.g.,
stomachaches and headaches) (Drake, Golda, & Ginsburg, 2014).
- Social Anxiety Disorder- Common, treatable anxiety disorder characterized by
physiological distress, avoidance, and fear of embarrassment, humiliation, and rejection
in social situations. Situations include: social interactions (having a conversation, meeting
unfamiliar people), being observed (eating or drinking), and performing in front of others
(giving a speech); Social situations often are avoided, resulting in distress or impairment
(Drake, Christofferson, & Keeton, 2017).
- Adjustment Disorder- Persistent maladaptive emotional or behavioral reaction within
several months of an identifiable stressful event or change in a person’s life (Lal &
Mackinnon, 2017).
Provisional Diagnosis:
- ADHD- Poor social/interpersonal functioning and negative self-attitude are common,
along with poor frustration tolerance and irritability (Burkey & Perry-Parrish, 2014).
- ASD- Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized
by impairments in two major areas (1) Social communication and social interaction; (2)
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Restricted and repetitive patterns of behavior, interests, and activities (Williams, & Ji,
2017).
Question: Is Katy too young to diagnose, or is there a basis for early identification and
intervention? No; Katy is of appropriate age to be diagnosed. Also, there are early identifications
and interventions to prevent other disorders that later manifest and continues into adulthood.
Anxiety disorders, including SAD, are highly comorbid and frequently co-occur with other
anxiety and mood disorders. Early intervention may provide immediate gains and prevent long-
term negative outcomes, such as the persistence of excessive anxiety into adulthood (Drake,
Golda, & Ginsburg, 2014).
Assessment Tools:
Patient/Parent:
Psychological Evaluation/Testing- a comprehensive assessment utilizing multiple testing tools
and questionnaires to determine mental diagnosis based off reported history of patient’s behavior.
Screen for Child Anxiety Related Emotional Disorders (SCARED)- self-report/parent tool used
to screen for anxiety and panic disorders and phobias
The Parent Version of the SPAI-C- an anxiety inventory report from the parent that identifies and
measures social phobias in a child.
Vanderbilt Assessment- a scored assessment from parent and teacher based on the child’s
behavior and academic performance in a school and home setting.
PLAN:
- No medication recommended at this time; Plan to evaluate on routine follow-up
appointments the need for pharmacotherapy.
- Recommend individual psychotherapy which is 1st line of treatment
Cognitive behavior therapy (CBT) for SAD is an empirically-supported treatment that
focuses on teaching children (and adults) new skills to reduce anxiety when separating from
attachment figures. CBT skills for managing SAD include: psychoeducation, in-vivo
exposure, cognitive restructuring, and relaxation training (Drake, Golda, & Ginsburg,
2014).
School-Based Treatment Plan:
- Conduct school meetings with parent, counselors, and teachers to identify ways/resources
to manage anxiety: psychoeducation, problem solving, and relaxation periods, creating a
safe area for the student to utilize to de-escalate anxiety and allowing frequent breaks and
quiet time to prevent feeling of being overwhelmed.
Incorporating treatment components into the general classroom curriculum has been found
to increase program sustainability for universal intervention programs. Applying this
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concept to targeted students with anxiety disorders, such as evaluating integration of school-
based programs into existing student services (eg, guidance counseling) (Herzig-Anderson,
Community Resources:
- Community recreational center
- Boys and girls club
- Community church
- Educational tools for parent/child: Worry Wise Kids; American Academy of Child and
Adolescent Psychiatry; Child Anxiety Network
- Educational books for parent/child: I don’t want to go to school: Helping children cope
with separation anxiety; Night light: A story for children afraid of the dark.

Family Implications:
- Recommend family therapy to better understand disorder and help child manage
symptoms.
- Encourage mother to talk with patient concerning illness and prognosis
Parent sessions can help parents learn to better manage their child’s behaviors by using
contingency management strategies, and reducing parental over protection and over control
(Drake, Golda, & Ginsburg, 2014).
Other Considerations:
Safety- Educate parent and patient on suicidal and/or homicidal ideation; Assess for aggressive
and violent behavior that may pose a risk to self and/or others.
Effectiveness- Implementing follow-up appointments to evaluate treatment response and assess
for new symptoms and/or complaints.
Compliance- Educating parent the importance of adhering to recommendation when managing
symptoms.
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References
Burkey, M., & Perry-Parrish, C. (2014). Attention-Deficit / Hyperactivity Disorder. In Johns
Hopkins Psychiatry Guide.
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787036
/all/ADHD
Drake, K., Christofferson, J., & Keeton, C. (2017). Social Anxiety Disorder. In Johns Hopkins
Psychiatry Guide.
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787055
/all/Social Anxiety Disorder
Drake, K., Golda, S., & Ginsburg, S. (2014). Separation Anxiety Disorder. In Johns Hopkins
Psychiatry
Guide.https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/
787052/all/Separation Anxiety Disorder
Herzig-Anderson, K., Colognori, D., Fox, J. K., Stewart, C. E., & Masia Warner, C. (2012).
School-based anxiety treatments for children and adolescents. Child and adolescent
psychiatric clinics of North America, 21(3), 655–668. doi:10.1016/j.chc.2012.05.006
Lal, R., & Mackinnon, D. F. (2017). Adjustment Disorder. In Johns Hopkins Psychiatry Guide.
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787068
/all/Adjustment_Disorder
Williams, J. C., & Ji, N. Y. (2017). Autism Spectrum Disorder. In Johns Hopkins Psychiatry
Guide.https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/
787035/all/Autism Spectrum Disorder
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