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]}