Explain school refusal and bullying plan to an adolescent and parent — OSCE

Candidate instructions

Explain that school refusal is a treatable behaviour linked to anxiety and bullying (not laziness or bad parenting), outline exposure-based CBT and a graded return-to-school, describe how the school will respond to the bullying and rebuild belonging, discuss reducing family accommodation without blame, cover when an SSRI such as sertraline might be added and how you monitor safety, and respond to the request for indefinite home schooling. The examiner plays the parent; a co-actor plays the young person. [1] [2] [5]

Candidate scenario

You are the paediatrician in clinic. A 14-year-old with 6 weeks of near-complete non-attendance, weekday morning nausea, and cyberbullying via a group chat is accompanied by a parent. No medical red flags after review. No active suicide plan, but intermittent hopelessness about school. School welfare is willing to meet this week. The parent requests "a few months off" and asks whether medication will fix the attendance. [1] [7]

Marking domains

• Empathy, structure and agenda-setting, including parental guilt and the certificate request [1]
• Accurate plain-language explanation of school refusal as anxiety-linked behaviour, not laziness [1] [5]
• Clear plan: graded return with school, exposure-based CBT, reduced accommodation, anti-bullying response and re-connection [6] [8]
• Balanced SSRI discussion: CAMS supports it for the anxiety driver; Melvin does not support superiority for attendance; Bridge-level monitoring [2] [3] [4]
• Check-backs, shared decision-making, and a written, dated plan with a named contact and review [7]

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, and the bullying on the chat is part of what made school feel unsafe." [1] [7]

Anxiety and the cycle. "Staying home brings relief for an hour, but it teaches the brain that school is genuinely dangerous, so the next morning is harder. Our job is small, supported steps back, not throwing her in the deep end. Counselling skills plus those steps are what the evidence supports." [5] [6]

Graded return with school. "With the school welfare lead we agree a ladder: a gate visit with a trusted adult, a short lesson, a half-day, then a full day. We measure attendance each week. During school hours we keep home low-reward so the brain relearns that school is the place to be. Your role is coach, not enforcer." [6]

The bullying response. "The bullying is a real and treatable part of this — programmes that work with the whole school reduce victimisation. We will have a specific plan for the chat and the peer group, capture evidence safely, report through the platform, and build her back into a safe adult and a group at school. Bullying carries a real link to low mood and thoughts of self-harm, so this is clinical care, not just a school matter." [8] [7]

Certificates. Decline indefinite home schooling and long certificates. Offer short, dated leave only if truly needed, paired with a written return date and the ladder. [1] [6]

Medication. "If her 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 than either alone or placebo. Another school-refusal study found adding fluoxetine did not clearly beat good therapy alone for attendance — so medicine treats the anxiety or mood, it is not a magic school pill. We start low, go slow, and watch closely, because a small number of young people feel more agitated or have new thoughts of self-harm when antidepressants start." [2] [3] [4]

Close. Written plan: school meeting this week, the ladder steps, who to call if risk rises, a review date, and the young person's questions invited. [7] [8]