Child and adolescent anxiety — school refusal, CBT and SSRI evidence (MEQ)

(i) Diagnosis and differentials. Most likely separation anxiety disorder with school refusal behaviour. Discriminators: weekday somatic symptoms that remit when separation is avoided, fear of harm to attachment figures, clinginess, preserved weekend function. Differentials: social anxiety (peer/evaluative fear), GAD (multi-domain worry), depression, ASD, ADHD, medical causes of abdominal pain, ODD/truancy (enjoyment of home without anxiety), PTSD, bullying-related avoidance (history negative here but always check). School refusal is not itself a DSM diagnosis.[5][7]

(ii) Assessment and functional analysis. Separate child and carer interviews; developmental and family anxiety history; attendance calendar; medical red-flag screen; risk (self-harm/suicide); school collateral. Kearney functions: (1) avoid negative affectivity, (2) escape aversive social/evaluative situations, (3) gain attention, (4) tangible rewards outside school. Here: strong negative-affectivity avoidance and attention/proximity reinforcement with gaming. Scales (SCARED/SCAS/RCADS) as adjuncts.[5][7]

(iii) Psychological and family treatment. First-line 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; externalise anxiety as the problem. CBT has systematic review/Cochrane support for youth anxiety; school-refusal CBT trials support structured behavioural approaches with caregiver involvement.[4][7][8]

(iv) Pharmacotherapy evidence and SSRI start. If moderate–severe, CBT inaccessible/ineffective, or combination planned: SSRI first-line. CAMS: CBT vs sertraline vs combo vs placebo — combo highest CGI response (~81%), CBT ~60%, sertraline ~55%, placebo ~24%. RUPP fluvoxamine superior to placebo for youth separation/social/GAD. Birmaher fluoxetine efficacious in childhood anxiety. Example start: sertraline 25 mg oral daily, titrate slowly (CAMS allowed up to 200 mg); or fluoxetine 10 mg oral daily titrating toward 20 mg as needed. Counsel activation, GI effects, sleep change, and suicidality monitoring (Bridge meta-analysis signal); early review; involve carers.[1][2][3][6]

(v) Return-to-school and legal/safety. Same-week school liaison; graded steps (brief on-site exposure → partial day → full day with support); remove high-value home rewards during school hours; treat underlying anxiety in parallel; medical certificates only for true medical unfitness with an exit plan. Safety: ongoing risk review if mood drops or SSRI started. Consent: collaborative care with parental responsibility for minors; capacity decision-specific; use local compulsory pathways only if risk and incapacity require — name jurisdiction, do not invent foreign section numbers.[5][7][8]