School refusal and school anxiety — functional analysis, CBT and return-to-school (MEQ)

(i) Definition and differentials. School refusal is a behaviour/presentation of difficulty attending school with emotional distress, typically with caregiver knowledge — not a freestanding DSM diagnosis. Differentials: social anxiety, separation anxiety, GAD, depression, ASD overload, learning disorder, bullying, medical disease, OCD/PTSD/psychosis prodrome, and truancy (often covert absence, less school fear, different externalising associations per Egger community data).[1][2][8]

(ii) Kearney functional analysis. (1) Avoid negative affectivity — morning nausea/panic reduced by staying home. (2) Escape aversive social/evaluative situations — presentations and canteen. (3) Attention/proximity — repeated cancellations and parental settling. (4) Tangible reinforcement — streaming at home. Rank mixed functions; here social-evaluative + negative-affectivity + tangible reward + accommodation are all active.[1]

(iii) Assessment and risk. Separate youth/carer interviews; attendance calendar; school collateral; bullying screen; neurodiversity/learning history; mood and suicide risk (passive death wishes — full ideation/intent/plan/means/protective factors); substances; family anxiety; medical red-flag screen. Scales (SCARED/SCAS/RCADS) as adjuncts. Safety plan and same-week review intensity if risk escalates.[2][7][8]

(iv) Psychological and school interventions. Exposure-based CBT: psychoeducation, hierarchy (brief on-site → partial day → full day; canteen/presentation steps), cognitive work on evaluation fears, contingency management (no high-value home leisure during school hours). Caregiver training to reduce last-minute cancellations and accommodation (Heyne; King). Same-week school liaison; graded return with supports that fade; do not wait for zero anxiety.[3][4][8]

(v) Medication. Not first-line for the behaviour alone. If moderate–severe social anxiety/impairment, CBT inaccessible/insufficient, or combination planned: SSRI (e.g. sertraline 25 mg oral daily titrating with monitoring; or fluoxetine 10 mg oral daily toward 20 mg as needed). CAMS: combo CBT + sertraline highest acute response for separation/social/GAD package. Melvin 2017: fluoxetine did not clearly beat CBT alone for anxious school-refusing adolescents — do not overclaim attendance superiority. Counsel activation and suicidality (Bridge); early review; involve carers. Avoid chronic benzodiazepines as primary plan.[5][6][7][8]