Pediatric Generalized Anxiety Disorder Case Study (Sarah Pam): Diagnosis, Neurotransmitters and Escitalopram
9 min read Case study: Sarah Pam
Sarah Pam, a 12-year-old Native-American CIS female, exhibits a range of symptoms that has occurred over the last year. She is consistently plagued by worry and experiences heightened anxiety when her parents leave her with a babysitter. She seems to be on edge and always feels something wrong will happen. After witnessing a car accident on the news, she has developed a fear that her parents will also experience a similar fate. This state of unease causes her to be on edge and hampers her ability to concentrate. Her anxiety has led to failure on two exams as she experiences blankness and difficulty focusing. Notably, a history of general anxiety is present within her family, with both her mother and father having undergone treatment for similar issues.
Questions:
- What diagnosis best describes what may be happening to Sarah?
- What neurotransmitters are involved with her current symptoms?
- What classification of medications would best treat her symptoms?
- Choose one medication from the chosen class and provide the following: FDA approvals; mechanism of action; time frame the patient should see results; common side effects; life-threatening side effects; starting dose you picked and why; common labs and baseline vitals collected, with reasoning.
1. Diagnosis: generalized anxiety disorder (F41.1)
Sarah’s presentation best fits generalized anxiety disorder (GAD). Under the DSM-5-TR, GAD requires (American Psychiatric Association [APA], 2022):
| DSM-5-TR criterion | Evidence in Sarah’s case |
|---|---|
| A. Excessive anxiety and worry about a number of events or activities, more days than not, for at least 6 months | “Consistently plagued by worry” for the past year; worries about her parents’ safety, being left with a babysitter, and that “something wrong will happen” |
| B. Difficulty controlling the worry | Persistent worry that she cannot set aside, even at school |
| C. At least one of six symptoms in children (three in adults): restlessness or feeling on edge, easy fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance | Feeling on edge; difficulty concentrating and mind going blank during exams |
| D. Clinically significant distress or impairment | Failed two exams; distress when parents leave |
| E. Not due to a substance or medical condition | Rule out hyperthyroidism, caffeine, medications |
| F. Not better explained by another mental disorder | See differential diagnoses below |
Her strong family history, with both parents treated for anxiety, further supports the diagnosis; GAD has a heritable component, and children of anxious parents are at higher risk.
Differential diagnoses
- Separation anxiety disorder (F93.0): Sarah’s distress when left with a babysitter and her fear that harm will come to her parents are classic features. If her worry is limited to separation from and harm to her parents, separation anxiety disorder may be the better diagnosis; if, as described, her worry is broad (“something wrong will happen,” school performance), GAD fits better. The two can also co-occur, and a thorough interview should clarify.
- Post-traumatic stress disorder or acute stress disorder: unlikely; watching an accident on the news is not a qualifying trauma exposure in DSM-5-TR (exposure through media does not count unless work-related), and she lacks intrusion and avoidance symptoms.
- ADHD, inattentive presentation: poor concentration could suggest ADHD, but her inattention appears linked to anxiety and is recent rather than lifelong.
- Major depressive disorder: screen for low mood, anhedonia and suicidal thoughts, which commonly co-occur with anxiety.
2. Neurotransmitters involved
Reduced serotonergic regulation of the amygdala and prefrontal cortex leads to persistent worry
The main inhibitory neurotransmitter; reduced GABA activity means less “braking” of fear circuits
Overactivity of the locus coeruleus causes hyperarousal, feeling on edge and poor concentration
Excitatory signaling that strengthens fear learning and worry
Anxiety involves an overactive amygdala (the brain’s threat detector) and weaker top-down control from the prefrontal cortex. Reduced serotonin and GABA signaling and excess norepinephrine and glutamate keep the fear circuit “switched on” (Stahl, 2021). In Sarah, this explains her constant sense of danger (amygdala, serotonin and GABA), feeling on edge (norepinephrine), and blanking during exams, since high arousal impairs prefrontal working memory and concentration. The stress hormone cortisol, through the HPA axis, also contributes.
3. Medication class: selective serotonin reuptake inhibitors (SSRIs)
SSRIs are the first-line medications for pediatric anxiety disorders, including GAD, separation anxiety disorder and social anxiety disorder. The American Academy of Child and Adolescent Psychiatry (AACAP) clinical practice guideline recommends cognitive behavioral therapy (CBT) and SSRIs for children and adolescents with anxiety disorders, and suggests combining CBT with an SSRI, particularly for moderate to severe symptoms or partial response (Walter et al., 2020). SNRIs (such as duloxetine) are an alternative. Benzodiazepines are not recommended for ongoing treatment in children because of dependence, sedation and paradoxical disinhibition.
4. Selected medication: escitalopram (Lexapro)
Escitalopram is a strong choice for Sarah because it is FDA-approved for GAD in children aged 7 and older, is generally well tolerated, has few drug interactions, and is dosed once daily.
| Item | Escitalopram (Lexapro) |
|---|---|
| FDA approvals |
(AbbVie, 2024) |
| Mechanism of action | Escitalopram is the S-enantiomer of citalopram. It selectively inhibits the serotonin transporter (SERT), blocking reuptake of serotonin into the presynaptic neuron and increasing serotonin in the synapse. Over weeks, this leads to downregulation of 5-HT1A autoreceptors and changes in fear circuits, reducing amygdala hyperactivity and worry. It has minimal effect on norepinephrine, dopamine, histamine or acetylcholine receptors, which explains its tolerability. |
| Time frame for results | Some improvement in sleep, tension or worry may appear in 2–4 weeks; meaningful anxiety reduction usually takes 4–8 weeks at a therapeutic dose, and full benefit may take 8–12 weeks. The pediatric GAD efficacy trial lasted 8 weeks. Continue for 6–12 months after remission before considering a slow taper. |
| Common side effects | Nausea, abdominal discomfort, headache, dizziness, insomnia or sleepiness, fatigue, decreased appetite, sweating, nasal congestion. In children, irritability, anxiety and anger (behavioral activation) were reported more often than with placebo (AbbVie, 2024). Sexual side effects mainly in older adolescents and adults. |
| Life-threatening side effects |
|
| Starting dose chosen and why | The labeled starting dose for pediatric GAD is 10 mg once daily, with increases to a maximum of 20 mg at intervals of no less than 2 weeks (AbbVie, 2024). For Sarah, I would start at 5 mg once daily for 1 week, then increase to 10 mg daily. Rationale: she is a 12-year-old who is SSRI-naive and highly anxious, and children are more prone to behavioral activation and GI side effects; “start low, go slow” improves tolerability and adherence while quickly reaching the labeled therapeutic dose. Reassess after 4 weeks at 10 mg and increase to 15–20 mg only if response is partial. Give in the morning if insomnia occurs. |
| Baseline labs and vitals | See below. |
Common labs and baseline vitals, with reasoning
| Assessment | Reasoning |
|---|---|
| Height, weight, BMI (plotted on growth charts) | SSRIs can reduce appetite and weight; the label advises regular monitoring of weight and growth in children (AbbVie, 2024). |
| Blood pressure and heart rate | Establish a baseline; anxiety can raise HR and BP, and medication effects can then be tracked. |
| Temperature | Baseline for recognizing serotonin syndrome if it occurs. |
| ECG (if indicated) | Not routinely required, but obtain if there is a personal or family history of cardiac disease, syncope, sudden cardiac death or congenital long QT, or if she takes other QT-prolonging drugs. |
| TSH (thyroid function) | Rule out hyperthyroidism, which can mimic anxiety (DSM criterion E). |
| CBC and CMP | Baseline sodium (hyponatremia risk), liver and kidney function for drug metabolism, and hematologic status given bleeding risk; also rules out medical causes of fatigue or poor concentration. |
| Urine pregnancy test (if post-menarchal) | Guides medication safety counseling in a 12-year-old female. |
| Urine drug screen (if clinically indicated) | Rule out substance-induced anxiety. |
| Rating scales | Columbia Suicide Severity Rating Scale (C-SSRS) at baseline and each visit because of the boxed warning; anxiety severity scale (GAD-7, SCARED or PARS) to measure response; screen for bipolar disorder and family history of bipolar disorder before starting an SSRI. |
Monitoring: follow up weekly by phone or in person for the first month, then every 2–4 weeks during titration, watching for suicidal thoughts, activation, side effects, weight and response.
Comprehensive treatment plan
- CBT: psychoeducation, cognitive restructuring of catastrophic thoughts (“My parents will die in a crash”), gradual exposure to separations, and relaxation skills. CBT is first-line and can be combined with escitalopram (Walter et al., 2020).
- Family involvement: because both parents have anxiety, teach them to model calm coping and avoid reinforcing avoidance; encourage their continued treatment.
- School support: coordinate with the school counselor; consider a 504 plan with testing accommodations, such as extended time or a quiet room.
- Limit distressing media, such as news coverage of accidents, and support healthy sleep and exercise.
- Cultural considerations: as a Native American youth, Sarah may benefit from culturally responsive care that respects family, community and traditional healing practices if the family wishes. Ask about her tribal identity and connect with Indian Health Service, tribal or urban Indian health programs where appropriate.
Related reading: depression, the DSM-5-TR and medications, family assessment and the stress response and stress hormones.
Conclusion
Sarah’s year-long, hard-to-control worry, feelings of being on edge and difficulty concentrating, with impaired school performance and a strong family history, best fit generalized anxiety disorder, with separation anxiety disorder as an important differential. Her symptoms reflect dysregulation of serotonin, GABA, norepinephrine and glutamate in the brain’s fear circuits. An SSRI is the first-line medication class, and escitalopram, FDA-approved for GAD in children 7 and older, is an appropriate choice, started at a low dose with careful monitoring for suicidality, activation and growth. Combined with CBT, family involvement and school support, this plan offers Sarah the best chance of recovery.
References
AbbVie. (2024). Lexapro (escitalopram) tablets: Prescribing information. U.S. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/021365s041lbl.pdf
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107–1124. https://doi.org/10.1016/j.jaac.2020.05.005
