Stomachaches Every School Morning: Treating Generalized Anxiety in a 12-Year-Old With CBT and Sertraline Together, and Planning for the Relapse That Follows in Almost Half of Responders
[Student Name]
University of Phoenix
PMH/505: Psychiatric Management Of Children And Adolescents
Week 3 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Ava, 12, has had stomachaches most school mornings for four months and has missed 15 days of sixth grade. Her pediatrician found no medical cause. She worries about grades, her parents' health, the weather and whether friends are angry with her; she asks for reassurance many times a day and has trouble falling asleep. Her Screen for Child Anxiety Related Disorders score is elevated for generalized anxiety. What follows describes her evaluation and plan.
Diagnosis
Generalized anxiety disorder in children requires excessive, hard-to-control worry spanning several areas of life, present more days than not across a half-year period, along with at least one bodily or mental companion symptom, for example feeling keyed up, tiring easily, a mind going blank, a short temper, tight muscles or poor sleep. Ava's worry began in fifth grade and has worsened, with somatic complaints, sleep difficulty and school avoidance. Separation anxiety is considered and excluded because she worries about many topics, not only separation, and sleeps over at friends' homes without distress. Depression screening is negative.
What the Trial Showed
Walkup et al. (2008) enrolled 488 youths between 7 and 17 years of age whose primary diagnosis was one of three common anxiety disorders and assigned them at random to CBT, sertraline, their combination or placebo for 12 weeks. Response rates were 80.7% with combination therapy, 59.7% with CBT and 54.9% with sertraline, compared with 23.7% with placebo, and combination therapy was superior to either alone. Suicidal ideation was not more frequent with sertraline than placebo, and CBT caused less insomnia, fatigue and restlessness than sertraline.
Confirming Across Studies
Drawing on 115 studies, Wang et al. (2017) and found that SSRIs increased remission and response compared with placebo, that CBT improved anxiety compared with wait-list or no treatment, that the combination of sertraline and CBT reduced symptoms more than either alone and that benzodiazepines and tricyclics did not significantly reduce anxiety. Adverse events were common with medications but not with CBT.
The best response came from doing both, and the family's job did not end when the stomachaches did.
Medical Workup
Recurrent abdominal pain in a child needs a medical evaluation before it is attributed to anxiety. Ava's pediatrician examined her, checked a complete blood count and celiac screen and found no cause. The pain occurs on school mornings, eases on weekends and during summer and is accompanied by worry, a pattern typical of anxiety. Telling the family clearly that the pain is real but driven by anxiety helps them accept treatment.
Family Patterns
Her mother also has anxiety and has, understandably, let Ava stay home when her stomach hurts. Accommodation relieves distress in the moment but maintains avoidance. Parents are taught to reduce accommodation gradually while supporting their child, an approach that can help even when the child is reluctant to engage.
Choosing With the Family
Ava's parents prefer to start with therapy alone. Given her 15 missed days and daily symptoms, I recommend combination treatment, explaining the trial's results and the boxed warning on antidepressants. They agree to start CBT immediately and sertraline in two weeks if she is not improving, a reasonable compromise.
CBT for Ava
CBT teaches Ava to recognize worry and its effect on her body, challenge catastrophic predictions, and face feared situations gradually. Her exposures include attending school through the morning even with a stomachache, reducing reassurance-seeking, first to three questions a day and then to one, and tolerating uncertainty about her grades. Parents learn to respond to reassurance requests with empathy but without repeated answers.
Measuring Anxiety at Baseline
Both Ava and her parents complete the Screen for Child Anxiety Related Disorders so that each informant's view is recorded before treatment starts. Her own ratings are higher than her parents', a common pattern in children whose worry is mostly internal and not visible to adults.
Sertraline
Sertraline is started at 25 mg daily and increased to 50 mg after a week, with further increases if needed. I explain common side effects, the need to watch for new or worsening suicidal thoughts, agitation or unusual behavior, especially early and after dose changes, and a schedule of visits every two weeks at first.
School Return
A plan with the school counselor allows Ava to go to the nurse for 10 minutes if a stomachache occurs, then return to class, rather than go home. A graded schedule restores full days over two weeks.
Why Anxiety Treatment Matters Early
Untreated childhood anxiety predicts later depression, substance use and continued anxiety in adulthood. School avoidance at twelve can become lasting academic and social setbacks if it becomes a habit. Early, effective treatment protects more than her mood this year.
Sleep
A consistent bedtime routine, a worry notebook used before bed, in which she writes each worry down and leaves it for the morning, and no screens in the hour before sleep address her insomnia.
Why Not a Benzodiazepine
Her parents ask about something for acute worry at bedtime. Wang et al. (2017) found that benzodiazepines did not significantly reduce anxiety in children, and they carry sedation and dependence risks. They are not used.
Assent
Ava is asked whether she agrees to the plan, not only her parents. She agrees to therapy readily and to medication after hearing that it would be checked often and could be stopped if she disliked how it made her feel.
Long-Term Course
Ginsburg et al. (2014) followed participants from the Walkup trial for a mean of six years and found that almost half were in remission, that acute responders were more likely to be in remission and that almost half of acute responders later relapsed, suggesting that many youths need continued or more intensive treatment. For Ava, this means planning ahead: sertraline continues for 6 to 12 months after remission before a slow taper during a low-stress period, and booster CBT sessions are scheduled at the start of seventh grade.
Friendships
Ava worries that friends are angry with her and avoids texting them first. A graded exposure has her start one conversation a day, then invite a friend over on a weekend. Friendships at this age are protective and give her evidence against her fears.
Measuring Progress
Ratings from Ava and her parents are repeated every four weeks. School attendance is the most meaningful outcome to her family, and it is tracked weekly. Sleep onset time and the number of reassurance questions per day are logged by her parents, giving concrete, shared evidence of change.
Conclusion
Ava has generalized anxiety disorder with somatic symptoms and school avoidance. A large trial and a meta-analysis support combining CBT with sertraline as the most effective treatment, and long-term follow-up shows that relapse is common even after good responses. Her plan combines both treatments, a structured school return and relapse prevention with continued medication and booster sessions.
References
Ginsburg, G. S., Becker, E. M., Keeton, C. P., Sakolsky, D., Piacentini, J., Albano, A. M., Compton, S. N., Iyengar, S., Sullivan, K., Caporino, N., Peris, T., Birmaher, B., Rynn, M., March, J., & Kendall, P. C. (2014). Naturalistic follow-up of youths treated for pediatric anxiety disorders. JAMA Psychiatry, 71(3), 310-318. https://doi.org/10.1001/jamapsychiatry.2013.4186
Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753-2766. https://doi.org/10.1056/NEJMoa0804633
Wang, Z., Whiteside, S. P. H., Sim, L., Farah, W., Morrow, A. S., Alsawas, M., Barrionuevo, P., Tello, M., Asi, N., Beuschel, B., Daraz, L., Almasri, J., Zaiem, F., Larrea-Mantilla, L., Ponce, O. J., LeBlanc, A., Prokop, L. J., & Murad, M. H. (2017). Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatrics, 171(11), 1049-1056. https://doi.org/10.1001/jamapediatrics.2017.3036
How this PMH 505 Week 3 example is structured
The PMH/505 Week 3 work usually focuses on pediatric anxiety disorders. This paper moves from diagnosis to an evidence-based choice among therapy, medication and their combination, then looks past the acute response to the long-term course. Students search this week as PMH 505 Week 3, PMH505 Wk 3 or PMH/505 Wk 3; all three are the same assignment.
PMH/505 Week 3 questions, answered
What does PMH/505 Week 3 usually ask for?
Many sections ask students to assess and treat anxiety disorders in children or adolescents, including psychotherapy, medication and family and school involvement.
Is CBT, sertraline or both best for childhood anxiety?
In a large randomized trial, response rates were about 81% with the combination, 60% with CBT alone and 55% with sertraline alone, compared with 24% with placebo; combination therapy was superior to either alone.
Do children stay well after anxiety treatment?
In a follow-up about six years after treatment, almost half of the sample was in remission, but almost half of those who had responded to acute treatment later relapsed.
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