School refusal, bullying and social exclusion — formative SAQs

SAQ 1 (10 marks)

A 14-year-old girl has attended only 9 of the last 40 school days. She develops nausea and panic-like symptoms on school mornings that resolve if she stays home. She recently stopped replying to a group chat after peers circulated an unflattering image; her phone now stays face-down and she avoids the canteen. She has intermittent passive death wishes when she feels hopeless about school but no plan. Her mother, exhausted, requests "a few months off" and asks about medication. Examination is normal; no nocturnal waking, weight loss or systemic features. [1] [9]

1. Formulate the presentation across the three overlapping drivers and list three immediate priorities before an attendance plan. (4) [9] [1]
2. Outline the first-line treatment and how you would structure the graded return and school response. (4) [4] [12]
3. Address the mother's request for time off and for medication, citing the relevant evidence. (2) [5] [6]

Model answer — SAQ 1

(1) Formulation and priorities (4). Three overlapping drivers: anxious school refusal behaviour (distress-driven non-attendance with caregiver awareness — morning nausea resolving at home), bullying victimisation (cyber harm via the group chat plus relational exclusion at the canteen), and social exclusion (loss of peer connection and phone withdrawal). Immediate priorities before an attendance plan: structured suicide risk assessment and safety planning (passive death wishes), medical red-flag screen for the somatic symptoms (negative here — no nocturnal waking, weight loss or systemic features), and a safeguarding/bullying assessment including whether cyber content involves images, threats or criminal material requiring police or child-protection escalation. [9] [1]

(2) Treatment and return (4). First-line is exposure-based CBT: psychoeducation, fear hierarchy, graded school exposures, cognitive work on catastrophic beliefs, and contingency management. Graded return moves the same week with school: gate visit, short classroom, partial timetable, full day; weekly attendance measurement; no high-value home leisure during school hours. Caregiver training reduces excessive reassurance and accommodation and coaches planned exposures. Pair this with a whole-school anti-bullying response (a Fraguas-level programme reduces victimisation) and active re-connection: a named safe adult, mentoring, and a canteen/peer plan. A digital safety plan sets device boundaries, captures evidence and reports through the platform. [4] [12]

(3) Time off and medication (2). Decline open-ended certificates or indefinite home schooling — each entrenches avoidance via negative reinforcement. Offer short, dated leave only if truly unfit, paired with a written reintegration date and graded plan. On medication: treat the underlying moderate–severe anxiety or depression, not "school refusal." CAMS supports CBT, sertraline and combination for childhood anxiety; Melvin found fluoxetine did not clearly beat CBT alone for school-refusal attendance — do not overclaim SSRI superiority for attendance. If an SSRI is indicated, start low (sertraline 25 mg oral daily; fluoxetine 10 mg oral daily), titrate slowly, counsel activation and suicidality (Bridge), and review early. [5] [6] [7]

SAQ 2 (10 marks)

A 15-year-old boy with autism spectrum disorder and anxiety has missed most of two school terms. He dreads a specific corridor and a peer group there; he reports being called names and shoved. He sleeps poorly, has stopped attending his lunchtime club, and his mother has been keeping him home to "keep him safe." He disclosed passive suicidal thoughts two days ago after a particularly bad online exchange. He has no plan or means. School wants a plan; the family wants home schooling. [8] [9]

1. State the red flags and the immediate management of the suicide disclosure. (3) [9] [11]
2. How does ASD change (and not change) the assessment and graded-return plan? (4) [8] [1]
3. Discuss the prognosis, disposition and safety-netting, including the regional service options. (3) [9] [12]

Model answer — SAQ 2

(1) Red flags and immediate management (3). Red flags: recent suicidal ideation following cyber and face-to-face victimisation, chronic non-attendance with deteriorating mood and sleep, and complete carer collapse into home confinement. Immediate management: full clinical suicide risk assessment (intent, plan, means, protection), same-day safety planning with means restriction, carer involvement and documentation; stabilise the acute mental state; capture and preserve the cyber evidence and escalate to police or child protection if criminal content is involved. Bullying is a modifiable contributor to suicidality, so treating it is part of the acute response. [9] [11]

(2) ASD — what changes and what does not (4). What does not change: school refusal is still formulated by Kearney function, the bully dynamic and belonging; graded exposure-based CBT with caregiver training remains first-line; and the principle of moving the same week with a reintegration date holds. What changes: sensory load (the corridor), communication supports, visual schedules and predictable transitions must be adapted. Avoid diagnostic overshadowing — do not attribute all distress to ASD and miss co-morbid anxiety, depression or abuse. Do not abandon exposure for phobic avoidance, but do not force "just try harder" without adapting the environmental demand. Address the named peer group and the specific corridor in the school safety plan. [8] [1]

(3) Prognosis, disposition and safety-netting (3). Earlier return predicts better outcome; chronic non-attendance, untreated co-morbidity and no trusted adult predict worse academic, social and mental-health outcomes. Disposition: this adolescent needs specialist child and adolescent mental-health involvement given suicidality and chronicity, alongside the school pathway. A whole-school anti-bullying programme and a restorative response to the named peer group are clinical care, not pastoral work. Safety-net: low-threshold re-access, a written plan, a named safe adult, a timed review, and who to call if risk rises. Regional options: ANZ school welfare plus CAMHS or youth mental-health pathways; UK pastoral support, Early Help and CAMHS; US school counsellor, 504/IEP and mental-health linkage; Canada school-board and mental-health services. [9] [12]