School refusal, bullying and social exclusion — branching viva

Opening

Examiner: Frame the adolescent whose attendance collapses after bullying. Why is this one problem with three drivers, not three separate problems? [1] [9]

Candidate: Because school refusal, bullying victimisation and social exclusion overlap and reinforce each other through a shared mechanism — lost school connection drives internalising distress, which deepens avoidance. The adolescent may be an anxious refuser, a cyber-victim and excluded from the peer group at the same time. I assess all three, formulate all three, and move on all three the same week. [1] [9]

Branch A — Classification and formulation

Examiner: How do you classify this presentation, and what is the Kearney functional analysis? [1]

Candidate: I classify on three axes: the attendance problem (anxious refusal versus truancy, withdrawal or exclusion), the bully role (victim face-to-face or cyber, perpetrator, bully-victim, bystander), and belonging plus severity. For Kearney, I rank the four functions — avoidance of negative affectivity, escape from aversive social or evaluative situations, attention-seeking, and tangible reinforcement outside school. Mixed functions are common, so I rank them from the history, the diary and the school collateral. [1] [2]

Probe: How do you separate anxious refusal from truancy? [2]

Candidate: Anxious refusal is distress-driven and the caregiver usually knows. 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 the pathways differ. [2]

Branch B — Assessment and risk

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

Candidate: I secure time alone and state conditional confidentiality. I build a multi-informant attendance map from school records, caregiver and youth, run HEEADSSS, and ask directly and separately about face-to-face and cyber victimisation and whether a trusted adult exists. Then I screen suicide risk with ASQ or Columbia and do a full clinical assessment of intent, plan, means and protection if positive. Anxiety does not protect against suicide — among victimised adolescents it raises the risk. [9] [8]

Probe: She disclosed passive death wishes yesterday. [9]

Candidate: That triggers same-day safety planning with means restriction, carer involvement and documentation, plus a full suicide risk assessment. I capture and preserve the cyber evidence and escalate to police or child protection if criminal content is involved. Safety comes before any attendance plan, but return-to-learning runs in parallel with treatment, not after perfect remission. [9] [11]

Branch C — Management

Examiner: What is first-line treatment? [4]

Candidate: Exposure-based CBT with caregiver training: psychoeducation, fear hierarchy, graded school exposures, cognitive work, contingency management, and reduced accommodation. Graded return moves the same week with school — gate, short classroom, partial timetable, full day — with weekly attendance measurement and no high-value home leisure during school hours. [4] [3]

Probe: What about the bullying itself? [12]

Candidate: A whole-school anti-bullying programme and a specific, restorative response to the bully dynamic, plus active re-connection through clubs, mentoring and a named safe adult. The Fraguas meta-analysis of randomised trials shows whole-school programmes reduce victimisation, so school intervention is clinical care. For the cyber harm, I add a digital safety plan with device boundaries, evidence capture and platform reporting. [12] [9]

Probe: When would you use an SSRI? [6]

Candidate: For moderate–severe underlying anxiety or depression, CBT inaccessible or ineffective, or combination when impairment is high — not for "school refusal" alone. CAMS supports CBT, sertraline and combination for childhood anxiety, with combination highest. Melvin is the caution: fluoxetine did not clearly beat CBT alone for school-refusal attendance, so I do not overclaim. I start low — sertraline 25 mg oral daily or fluoxetine 10 mg oral daily — titrate slowly, counsel activation and suicidality, and review early. Bridge reminds me there is a small absolute increase in reported suicidal ideation and attempts. [6] [5] [7]

Branch D — Stumpers

Examiner: The parents want home schooling for the rest of the year. [1]

Candidate: I decline open-ended certificates and indefinite home schooling — each entrenches avoidance via negative reinforcement. If short leave is truly needed, it is dated and paired with a written reintegration date and graded plan. Attendance goals run in parallel with anxiety treatment, not after symptom remission. [1] [3]

Examiner: She has autism and sensory overload in a specific corridor. Same plan? [8]

Candidate: Same graded-return principles, adapted: sensory plan, visual schedule, predictable transitions, communication supports. I avoid diagnostic overshadowing — ASD does not exclude co-morbid anxiety, depression or abuse. I do not abandon exposure for phobic avoidance, and I do not force "just try harder" without adapting the corridor and the demand. [8] [9]

Close

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

Candidate: Three overlapping drivers, one plan — function plus bully role plus belonging; exclude suicide and safeguarding first; expose, return this week with school, treat the anxiety or mood driver, monitor, and never leave an open-ended certificate. [1] [6] [9]