Explain school refusal plan and possible SSRI to parents — OSCE

Candidate instructions

Explain school refusal as a treatable behaviour linked to anxiety (not bad parenting or laziness), outline exposure-based CBT and graded return-to-school, discuss reducing accommodation without blame, cover when an SSRI might be added and safety monitoring, check understanding, and respond to the request for indefinite home schooling. The examiner plays a parent. [1] [2] [5]

Candidate scenario

You are the paediatrician in clinic. Parents of a 12-year-old with 6 weeks of near-complete non-attendance, weekday morning nausea, and fear of separation/presentations request a long medical certificate and home schooling. No medical red flags after review. No active suicide plan; intermittent hopelessness about school. School is willing to meet this week. [1] [8]

Marking domains

• Empathy, structure, agenda-setting (including parental guilt and certificate request)
• Accurate plain-language model: school refusal as behaviour; anxiety as driver
• Clear explanation of graded exposure return and reduced accommodation (not blame)
• Balanced SSRI discussion (CAMS combination rationale; Melvin caution in simple terms)
• Monitoring for activation and suicidal thoughts; early review plan
• Safety-net and shared written plan with school meeting date

Model outline

Open. Name the problem without blame: “Missing school has become a pattern that briefly turns the anxiety alarm down, so the brain learns school is dangerous. That is school refusal — a behaviour we can reverse. It is not laziness and not simply bad parenting.” [1] [8]

CBT and school. “Treatment is small, supported steps back into school with coping skills — not throwing them in the deep end without a plan. Your role is coach: fewer last-minute cancellations, more planned steps we agree with school.” Caregiver training supports outcomes. [5] [6]

Certificates. Decline indefinite home schooling; offer short leave only if truly needed with a written return date and hierarchy. [1] [6]

Medication. “If anxiety stays high, an SSRI such as sertraline can help the alarm settle. A large study found therapy plus sertraline helped more young people with anxiety get much better than either alone or placebo. Another school-refusal study found adding fluoxetine did not clearly beat good CBT alone for attendance — so medicine is for the anxiety/mood problem, not a magic school pill. We start low, go slow, review early.” [2] [3]

Safety monitoring. “A small number of young people can feel more agitated or have new thoughts of self-harm when antidepressants start. Uncommon but important — we watch closely and you contact us urgently if mood or safety changes.” [4]

Close. Written plan: school meeting this week, hierarchy steps, who to call if risk rises, review date, invite questions. [7]