SOAP Note: Separation Anxiety in a 9-Year-Old Boy

Subjective

Patient Information: The patient is a 9-year-old boy.

Chief Complaint (CC): Patient feels "worried."

History of Present Illness (HPI): The patient is a 9-year-old boy who presents with anxiety and worry. He reports feeling worried and anxious most of the time. He also has difficulties sleeping and is afraid of being left alone in his room at night. He has been experiencing nightmares themed around losing and being unable to find his mother or brother. He has difficulties in school in terms of relating to other children and has gotten into trouble in the past for throwing objects. He does not like staying in school for extended periods of time and is often worried about his mother dying or failing to pick him up after school. He frequently complains of headaches or stomachaches — particularly when at school and wanting to go home. The client also wets the bed at night and has lost several pounds over the past few weeks.

Current Medications: None. The client was referred by the family pediatrician, who believes there is nothing physically wrong with the child.

Allergies: No known allergies (NKA).

Past Medical History (PMHx): Patient's immunizations are current.

Substance Use History: The client has no history of substance use or abuse.

Social History (Soc Hx): The client is in grade 4. He appears to be experiencing difficulties in his relationships with other children at school.

Family History (Fam Hx): The patient lives with his mother and younger brother. His father was a military serviceman who was killed in combat. There is no known history of mental illness among first-degree relatives.

Objective

Mental Status Exam (MSE): The patient is well-groomed; however, a faint ammonia-like odor is noted, likely a consequence of poor hygiene related to enuresis. His posture is appropriate. He is frequently distracted and appears to have difficulty maintaining focus on a single task for an extended period. There is no evidence of psychomotor agitation or retardation. In terms of mood, the client appears tense. His thought content may be characterized as delusional in quality. His insight is fair, and his judgment is also fair.

Assessment and Differential Diagnoses

1. Separation Anxiety Disorder (SAD) — Primary Diagnosis

The primary diagnosis in this case is Separation Anxiety Disorder (SAD). The client presents with a number of symptoms consistent with this disorder under the DSM-5. As Vaughan, Coddington, Ahmed, and Erel (2016) observe, SAD is one of the most common disorders among school-age children. In the authors' words, some of SAD's many consequences include, but are not limited to, "excessive worry, sleep problems, distress in social and academic settings, and a variety of physical symptoms" (Vaughan et al., 2016, p. 311).

Per DSM-5 criteria, individuals presenting with SAD demonstrate anxiety or fear deemed excessive regarding imminent separation from attachment figures such as parents. This anxiety or fear must be evidenced by a minimum of three symptoms out of a total of eight. The client in this case presents with four of those symptoms.

First, the client presents with "persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death" (Goldstein & DeVries, 2016, p. 236). When at school, the client persistently worries about the wellbeing of his mother and younger brother. As his mother reports, the client frequently fears that she will die or will not arrive to pick him up.

Second, the client demonstrates "persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings" (Goldstein & DeVries, 2016, p. 236). He consistently wants to leave school and return home.

Third, the client reports recurrent nightmares with a separation theme (Goldstein & DeVries, 2016). He frequently dreams of losing and being unable to find his mother and brother — a hallmark feature of SAD.

Fourth, the DSM-5 associates SAD with "repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated" (Goldstein & DeVries, 2016, p. 237). The client's mother confirms that he regularly uses headaches and stomachaches as reasons to avoid attending school.

2. Generalized Anxiety Disorder (GAD) — Ruled Out

Generalized Anxiety Disorder (GAD) may be broadly defined as tension or worry that appears excessive in relation to daily activities — worry that overwhelms the individual and prevents them from engaging in key day-to-day tasks (Gale & Millichamp, 2016). Under the DSM-5, a primary presenting feature of GAD is anxiety and worry occurring most days over a period of at least six months. The client does report worrying about nearly everything most of the time.

Additionally, the DSM-5 requires that the worry be overwhelming and difficult for the person to control — a feature clearly evident in this case. The DSM-5 criteria also lists six associated symptoms, of which three must be present for a GAD diagnosis. These include restlessness or feeling keyed up, easy fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance (Goldstein & DeVries, 2016, p. 412). The client presents with two to three of these symptoms: sleep disturbance, irritability (as evidenced by throwing objects), and difficulty concentrating (resulting in a change of seating in class).

However, under the DSM-5, a GAD diagnosis requires that the disturbance not be better explained by another mental disorder, including separation anxiety (Goldstein & DeVries, 2016). In this case, there is clear evidence that the client's anxiety is primarily driven by fear of separation from his mother and brother. GAD is therefore ruled out as the primary diagnosis.

3. Post-Traumatic Stress Disorder (PTSD) — Considered but Ruled Out

As Kolaitis (2017) notes, "many children and adolescents are exposed to different types of trauma, e.g. abuse or various disasters" (p. 77). The DSM-5 diagnostic criteria are useful in evaluating a possible PTSD diagnosis. For a PTSD diagnosis, an individual must have been exposed to or witnessed a traumatic event (Goldstein & DeVries, 2016). In this case, the death of the client's father — and his permanent absence from the child's life — may be hypothesized as the traumatic event.

The individual must also display intrusion symptoms traceable to the event, including trauma-themed dreams and distress upon exposure to reminders of the event. The client does experience recurrent dreams involving the loss of attachment figures, and separation from those figures triggers distress — mirroring the separation from his father. Additionally, the client appears to avoid school, possibly associating leaving his mother with the experience of his father leaving and never returning.

Although the client displays some irritable behaviors (such as throwing an object at a classmate) and concentration difficulties, he does not exhibit self-destructive behavior. Importantly, this diagnosis can be ruled out because the client's distress appears more closely tied to the ongoing effects of separation from his father — which occurred when the client was approximately 5 years old — than to a discrete re-experiencing of that traumatic loss. The client himself notes that his classmates "do not appear to understand how somebody feels when their father leaves and never comes back," and he worries about losing his mother in the same way, stating: "What if my mom doesn't come home too?" This pattern is more consistent with SAD than with PTSD as the primary diagnosis.