School refusal and school attendance problems — formative SAQs

SAQ 1 (10 marks)

A 10-year-old boy has missed 8 of the last 12 school weeks. He develops abdominal pain and panic-like symptoms on weekday mornings that resolve if allowed to stay home gaming with his mother nearby. He fears something bad will happen to his parents if he leaves. At weekends he is bright and plays with cousins. Teachers describe clinginess at drop-off and no bullying. Parents give extensive reassurance and often keep him home “to settle”. MSE: tense, tearful when school is mentioned, no suicidal ideation. [1] [2]

1. State the most likely formulation and list three differentials with discriminators. (3) [1] [2]
2. Outline Kearney functional analysis for this presentation. (3) [1]
3. Describe first-line psychological and family treatment, including graded return principles. (4) [3] [4]

Model answer — SAQ 1

(1) Formulation and differentials (3). Most likely separation anxiety with anxious school refusal behaviour (not a freestanding DSM diagnosis of “school refusal”). Discriminators: weekday somatic symptoms remitting when separation is avoided; fear of harm to attachment figures; clinginess; preserved weekend function. Differentials: social anxiety (peer/evaluative fear); depression (global anhedonia/hopelessness); truancy/ODD (covert absence, little anxiety); medical abdominal disease (nocturnal/progressive red flags); bullying (specific peers/locations — history negative here). [1] [2]

(2) Kearney functions (3). (i) Avoidance of negative affectivity (primary — morning distress relieved by staying home). (ii) Attention/proximity reinforcement with mother nearby. (iii) Tangible rewards (gaming during school hours). Social-evaluative escape is less dominant if no peer/presentation fear is described. Rank mixed functions from diary and school collateral. [1]

(3) Treatment (4). Exposure-based CBT: psychoeducation, fear hierarchy, graded separation and school exposures, cognitive work on catastrophic separation beliefs, contingency management. Family: reduce excessive reassurance and accommodation; coach parents to support planned exposures rather than open-ended staying home. Graded return same week with school: concrete steps (gate → short classroom → partial timetable → full day); no high-value home leisure during school hours; weekly attendance measurement. [3] [4]

SAQ 2 (10 marks)

A 13-year-old girl has attended only 12 full days this term. She develops nausea and panic-like symptoms on school mornings that resolve if she stays home streaming shows. She fears class presentations and eating in the canteen. Parents cancelled school repeatedly “to settle her nerves” and now struggle to get her out of bed. Teachers report she is bright but avoids oral work; no clear bullying. MSE: tense when school is discussed; intermittent passive death wishes without plan when hopeless about school; no psychosis. Parents request indefinite home schooling and ask about medication. [1] [5] [6]

1. List red flags and immediate priorities before a pure attendance plan. (3) [7] [8]
2. Outline when an SSRI might be considered and the key evidence caveats (CAMS vs Melvin). (4) [5] [6]
3. Explain why open-ended home schooling is unhelpful and what certificate practice is safer. (3) [1] [3]

Model answer — SAQ 2

(1) Red flags and priorities (3). Passive death wishes require structured suicide/self-harm risk assessment and safety planning same day if escalating. Screen medical red flags for somatic symptoms. Assess safeguarding/bullying. Complete non-attendance with carer collapse and mood symptoms may need specialist mental-health intensity, not watchful waiting. Do not start open-ended home leave before risk and formulation. [7] [8]

(2) SSRI evidence (4). Medication is for moderate–severe underlying anxiety/depression, CBT inaccessible/ineffective, or combination when impairment is high — not a magic school pill. CAMS: CBT vs sertraline vs combo vs placebo for separation/social/GAD — combo highest acute CGI response; CBT and sertraline each beat placebo. Melvin: CBT ± fluoxetine in anxious school-refusing adolescents — fluoxetine augmentation did not clearly beat CBT alone for key attendance outcomes; avoid overclaiming SSRI superiority for school-refusal attendance specifically. Start low (e.g. sertraline 25 mg oral daily; fluoxetine 10 mg oral daily), titrate slowly, counsel activation and suicidality, early review. [5] [6] [7]

(3) Home schooling and certificates (3). Indefinite home schooling without a reintegration plan entrenches avoidance via negative reinforcement. Short medical certificates only if truly unfit, always paired with a written return date and graded plan. Attendance goals run in parallel with anxiety treatment, not after perfect symptom remission. [1] [3]