Separation Anxiety Disorder (SAD) in a Child who Has Not Seen His Father in Two Years
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Required /Optional Readings (click to expand/reduce)
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)
Chapter 9, “Anxiety Disorders”
Chapter 10, “Obsessive-Compulsive and Related Disorders”
Chapter 11, “Trauma- and Stressor-Related Disorders”
Chapter 12, “Dissociative Disorders”
Chapter 26, “Physical and Sexual Abuse of Adults”
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
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Chapter 26, “Psychosocial Adversity”
Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
Chapter 29, “Child Maltreatment”
Chapter 30, Child Sexual Abuse”
Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
Chapter 59, “Post Traumatic Stress Disorder”
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
Chapter 12, “Anxiety Disorders”
Document: Career Planner Guide
Document: Focused SOAP Note Template
Document: Focused SOAP Note Exemplar
Required Media (click to expand/reduce)
Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs) [Video].
Dartmouth Films. (2018, September 25). Resilience [Video]. YouTube. https://www.youtube.com/watch?v=bAXZVYDNURY
NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuse [Video]. https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video
Walden University. (2021). Case study: Dev Cordoba. Walden University Blackboard. https://class.waldenu.edu
Separation Anxiety Disorder (SAD) in a Child who Has Not Seen His Father in Two Years
CC (chief complaint): The mother of the child claims that he has sleep problems, feels unloved, and is frequently restless and frightened. He is impatient and agitated, throwing objects around the house and at school. He sleeps with the lighting on and the door open at night, and he misses meals, resulting in weight loss. Finally, he claims to have headaches and stomach issues on a regular basis.
HPI: The patient in this case is accompanied by his mother to the clinic. He is seven years old and white. He has no prior history of the psychological issues he is experiencing. The symptoms first occurred a year ago, but have recently gotten severe. The symptoms are frequent and hard to ignore throughout the day and night. When at school and away from the mother, the symptoms worsen. He gets relief when not asleep and with company. The symptoms are there during the day, but they get more severe at night when he is alone in his room without his mother. The severity of his symptoms is given a 7/10 rating by the accompanying adult.
Substance Current Use: There is no history of substance abuse in the family. There was no drinking by the mother during his pregnancy. She is currently drug-free and does not drink. The mother is adamant about not disclosing any information regarding the deceased father’s status on substance or alcohol abuse.
Medical History: He has no previous admissions or chronic illnesses.
- Current Medications: Over-the-counter (OTC) Melatonex for sleep.
- Allergies: The boy has no known allergies to anything.
ROS (Only Positives):
- GENERAL: Weight loss is reported.
- HEENT: Mentions headaches but dismisses light sensitivity or vision problems.
- CARDIOVASCULAR: He denies chest discomfort but states that he sometimes gets palpitations.
- GASTROINTESTINAL: Has constant abdominal pains, especially at school, although they disappear when he goes home. He claims to have a sluggish appetite and only eats when he is hungry.
Diagnostic results: The laboratory and imaging tests reveal no physical abnormalities.
Mental Status Examination
The client is a white boy of seven years old. He is alert and oriented in all spheres. He’s also dressed correctly for the weather and the time of day. There are no obvious motions or characteristics in the boy. His self-reported mood is “unhappy,” and his affect is dysphoric, which means the two are in sync. He admits to having suicidal ideas but denies having homicidal ones. There are no delusions or hallucinations. His insight and judgment are altered, which is to be anticipated because of his age.
Diagnostic Impression and Differential Diagnoses
- Separation Anxiety Disorder (SAD) – 309.21 (F93.0)
This is the primary diagnosis for this boy as the diagnosis of separation anxiety disorder is age-dependent. Some of the main diagnostic criteria as found in the DSM-5 are:
- Feeling anxious because the child fears that they may be separated from a parent or guardian,
- Feeling overly distressed when the child thinks about the possible separation,
- Experiencing a sense of threat that is overstated concerning the possibility of separation,
- Suffering from the fear of remaining on one’s own in a dark room especially at night when sleeping,
- Experiencing nightmares,
- Not wanting to do to school out of fear that maybe the child may come back and find that the remaining parent has also disappeared, and
- Persistent but unfounded complaints about physical symptoms such as stomachaches and headaches, which are in reality just psychosomatic in nature (APA, 2013; Sadock et al., 2015).
Based on the diagnostic criteria for separation anxiety disorder, it can be safely concluded that this boy meets the requirements to be diagnosed with the condition (APA, 2013).
- Posttraumatic Stress Disorder (PTSD) – 309.81 (F43.10)
In this case, the symptoms of SAD and PTSD are so close that it’s possible that this youngster’s SAD was misdiagnosed as PTSD. However, the most crucial diagnostic requirement for PTSD is that it must have been brought on by a stressful event (APA, 2013; Sadock et al., 2015). The hypothesis of psychological trauma to this boy is feasible and probable. However, it does not seem possible judging by the fact that for the two year that his father has been missing no n really told him what had happened to the father. That hypothesis can therefore hardly stand and that is why this diagnosis is not the primary diagnosis but a possible differential. He is also still too young to comprehend the situation. The DSM-5 criteria for PTSD that must be met, even if only in part include history of a traumatic experience, and unsettling recollections of the traumatic experience that one cannot get rid of on his own.
- Generalized Anxiety Disorder (GAD) – 02 (F41.1)
SAD and GAD belong to the same group of disorders in the DSM-5. The two anxiety disorders share a lot of similarities in terms of symptomatology and general presentation; so much so that it is very easy to misdiagnose one for the other. A key distinguishing characteristic however is that the anxiety and distress experienced in SAD is due to the disappearance of a parent or guardian to the child client (APA, 2013; Sadock et al., 2015). The presence of GAD manifestations is associated with clinically significant impairment in functioning.
Since the evaluation and management of this child was done by following laid down procedures and practices, it would be honest to say that I would be quick to repeat the same procedures again next time (Carlat, 2017). Being a minor, all matters requiring consent were directed towards the adult accompanying the boy. I made particularly sure that the four bioethical principles advanced by Beauchamp and Childress of autonomy, beneficence, nonmaleficence, and justice were observed (Haswell, 2019). This included explaining to the mother all procedures so that she could offer informed consent. In the spirit of autonomy, I also asked her for her opinion before offering any intervention or suggestion. For any condition suffered by anyone, close observation and assessment would reveal that particular social determinants of health are responsible. In this case, the socioeconomic status of the family and their ability to get access to quality healthcare services were the main ones ((Powell, 2016). The former is determined by family income (that dropped when the breadwinner died in war), while the latter is determined by healthcare insurance coverage (that cannot be the same as when the breadwinner was alive and employed).
Case Formulation and Treatment Plan:
Because this is a minor, the selective serotonin reuptake inhibitor (SSRI) sertraline will be prescribed off-label at 25 mg orally daily (Stahl, 2017). Evidence-based practice (EBP) suggests that pharmacotherapy combined with psychotherapy produces better patient outcomes. For this reason, the child will also be started on cognitive behavioral psychotherapy or CBT on a weekly basis (Corey, 2017; Wheeler, 2020).
American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Carlat, D.J. (2017). The psychiatric interview, 4th ed. Wolters Kluwer.
Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.
Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177
Powell, D.L. (2016). Social determinants of health: Cultural competence is not enough. Creative Nursing, 24(1), 5-10. http://dx.doi.org/10.1891/1078-4522.214.171.124
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.
Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice, 3rd ed. Springer Publishing Company, LLC.