Psych · Child and adolescent psychiatry — school refusal and school anxiety
School refusal and school anxiety
Also known as School avoidance · School phobia (historical term) · Anxious school refusal · School non-attendance · School reluctance · Kearney functional model · Return-to-school plan
Exam-exhaustive fellowship reference on school refusal and school anxiety — behaviour not diagnosis, Kearney four-function analysis, Egger community psychiatry associations, exposure-based CBT and caregiver training, graded return-to-school, SSRI evidence for underlying anxiety (CAMS) and Melvin fluoxetine augmentation, family accommodation, and stepped care. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Active suicidal ideation, intent or plan, or escalating self-harm in a non-attending youth — same-day risk assessment, not 'just school stress'
- Complete prolonged non-attendance with carer collapse, severe depression, or inability to leave home — escalate CAMHS intensity and school liaison urgently
- Medical red flags with somatic complaints (weight loss, dehydration, focal neurology, unexplained fever) — medical review before pure psychiatric framing
- Safeguarding concerns (abuse, neglect, bullying with safety risk, coercion, exploitation) disclosed during school-refusal assessment — escalate per local child-protection pathways
- Marked behavioural activation or new suicidal thinking after starting an antidepressant — urgent review
- Open-ended medical certificates or indefinite home schooling without a graded reintegration plan — iatrogenic entrenchment of avoidance
Meet the patient
An 11-year-old has not been to school for three weeks. Sunday nights are unbearable; Monday mornings bring vomiting that magically resolves by midday. Her mother, exhausted, holds a stack of medical certificates. The registrar reaches for an SSRI. The examiner wants the functional analysis first.[1][3]
The question on this ward round is never "is this school phobia". It is "what is the behaviour achieving, what is it not, and what is your first move?" Answer those three, in order.[1][10]
References14ShowHide
- [1]Kearney CA, Albano AM. The functional profiles of school refusal behavior. Diagnostic aspects Behav Modif, 2004.PMID 14710711
- [2]Kearney CA. Forms and functions of school refusal behavior in youth: an empirical analysis of absenteeism severity J Child Psychol Psychiatry, 2007.PMID 17244270
- [3]Egger HL, Costello EJ, Angold A. School refusal and psychiatric disorders: a community study J Am Acad Child Adolesc Psychiatry, 2003.PMID 12819439
- [4]King NJ, Tonge BJ, Heyne D, Pritchard M, et al. Cognitive-behavioral treatment of school-refusing children: a controlled evaluation J Am Acad Child Adolesc Psychiatry, 1998.PMID 9549960
- [5]Heyne D, King NJ, Tonge BJ, Rollings S, et al. Evaluation of child therapy and caregiver training in the treatment of school refusal J Am Acad Child Adolesc Psychiatry, 2002.PMID 12049443
- [6]Melvin GA, Dudley AL, Gordon MS, Klimkeit E, et al. Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial Child Psychiatry Hum Dev, 2017.PMID 27485100
- [7]Bernstein GA, Borchardt CM, Perwien AR, Crosby RD, et al. Imipramine plus cognitive-behavioral therapy in the treatment of school refusal J Am Acad Child Adolesc Psychiatry, 2000.PMID 10714046
- [8]Walkup JT, Albano AM, Piacentini J, Birmaher B, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety N Engl J Med, 2008.PMID 18974308
- [9]James AC, Reardon T, Soler A, James G, Creswell C. Cognitive behavioural therapy for anxiety disorders in children and adolescents Cochrane Database Syst Rev, 2020.PMID 33196111
- [10]Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, et al. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders J Am Acad Child Adolesc Psychiatry, 2020.PMID 32439401
- [11]Bridge JA, Iyengar S, Salary CB, Barbe RP, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials JAMA, 2007.PMID 17440145
- [12]Connolly SD, Bernstein GA Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders J Am Acad Child Adolesc Psychiatry, 2007.PMID 17242630
- [13]Wang Z, Whiteside SPH, Sim L, Farah W, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis JAMA Pediatr, 2017.PMID 28859190
- [14]Birmaher B, Axelson DA, Monk K, Kalas C, et al. Fluoxetine for the treatment of childhood anxiety disorders J Am Acad Child Adolesc Psychiatry, 2003.PMID 12649628