CBT for Child Separation Anxiety in Structural Violence: A Two-Case Series With Follow-Up

This case series presents two Ecuadorian children, an 8-year-old boy and a 12-year-old girl, diagnosed with separation anxiety disorder precipitated by events linked to the country’s structural violence crisis. Both received adapted cognitive-behavioral therapy (CBT) based on the Kendall model, but treatments were prematurely interrupted by systemic barriers derived from the violence itself: economic precarity in one case, occupational displacement in the other. Follow-up evaluations conducted 17-23 months post-interruption using the Spence Children’s Anxiety Scale (SCAS) revealed divergent trajectories. The boy, whose parents actively engaged as co-therapists, showed a 58% reduction in total anxiety scores, with separation anxiety dropping from 16/18 to 5/18. The girl, whose caregivers minimized her distress, showed a 32% reduction, but her generalized anxiety remained unchanged and the item “I worry that something bad will happen to someone in my family” persisted at maximum score, the same cognition she had identified during treatment as a thought that “cannot become a butterfly.” These findings illustrate a clinical dilemma for cognitive restructuring when children’s catastrophic cognitions reflect genuine environmental threats.