School refusal and school attendance problems — branching viva

Opening

Examiner: Define school refusal for a general paediatrics viva. [1]

Candidate: School refusal is a behaviour, not a freestanding diagnosis: difficulty attending school with emotional distress, usually with caregiver knowledge of the absence. I formulate drivers and maintaining functions rather than coding “school phobia.” [1] [2]

Branch A — Classification

Examiner: How do you distinguish anxious refusal from truancy? [2]

Candidate: Anxious refusal shows distress-driven non-attendance and parents usually know. Truancy is often covert, with less school-related anxiety and more externalising or peer-linked skipping. Egger’s community work shows different psychiatric profiles — so pathways differ. [2]

Examiner: Name Kearney’s four functions. [1]

Candidate: Avoidance of negative affectivity; escape from aversive social/evaluative situations; attention-seeking; tangible reinforcement outside school. Mixed functions are common — I rank them from history, diary, and school collateral. [1]

Branch B — Assessment and risk

Examiner: What must you cover before writing a certificate? [8]

Candidate: Separate child and carer interviews; attendance calendar; medical red flags for somatic symptoms; bullying/safeguarding; developmental/neurodiversity history; mood and suicide risk; school collateral. Anxiety does not protect against suicide. [2] [8]

Probe: Parents demand a three-month certificate. [1]

Candidate: I will not issue open-ended certificates. If short leave is truly needed, it is time-limited and paired with a written reintegration date and graded plan — otherwise I entrench avoidance. [1] [3]

Branch C — Management

Examiner: First-line treatment? [3]

Candidate: Exposure-based CBT with caregiver training: hierarchy, graded school exposures, reduce accommodation, contingency management, school liaison. Attendance goals run in parallel with anxiety treatment. [3] [4]

Probe: When medication? [5]

Candidate: For moderate–severe underlying anxiety or depression, CBT unavailable/ineffective, or combination when impairment is high — not for “school refusal” alone. CAMS supports CBT, sertraline, and especially combination for separation/social/GAD. Melvin: fluoxetine did not clearly beat CBT alone for adolescent school-refusal attendance — I will not overclaim. Counsel activation and suicidality; early review. Example starts: sertraline 25 mg oral daily; fluoxetine 10 mg oral daily, titrate slowly. [5] [6] [7]

Branch D — Stumpers

Examiner: Morning pain vanishes at weekends — what next? [2]

Candidate: Think school-related anxiety pathway after red-flag medical screen. Replace medical shopping with functional analysis and graded return. [2]

Examiner: ASD plus school distress — same plan? [8]

Candidate: Same graded return principles, adapted: sensory plan, visual schedules, predictable transitions. Do not abandon exposure for phobic avoidance, and do not force “just try harder” without load adaptation. [8]

Close

Examiner: One-line take-home. [1]

Candidate: Function first, expose, school this week, SSRI only for the anxiety/mood driver with monitoring — never open-ended certificates. [1] [3] [5]