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]