School refusal and school anxiety — structured clinical viva

Nosology. School refusal is a behaviour needing functional analysis, not a freestanding DSM diagnosis. Map DSM drivers (separation, social anxiety, GAD, depression) separately from the attendance problem.^[1][2]

Kearney functions. Avoid negative affectivity; escape aversive social/evaluative situations; attention-seeking; tangible reinforcement outside school. Mixed functions are common.^[1]

Egger. Anxious refusal and truancy have different community psychiatric associations — tailor intervention.^[2]

CBT core. Exposure hierarchies + caregiver contingency training (King; Heyne). Graded school return is treatment, not aftercare.^[3][4]

Drugs. Melvin: fluoxetine did not clearly outperform CBT alone for anxious school-refusing adolescents. CAMS anchors combo CBT + sertraline superiority for underlying youth anxiety disorders. Bernstein imipramine+CBT is a historical school-refusal pharmacotherapy anchor; modern first-line meds are generally SSRIs with monitoring, not routine TCAs.^[5][6][7][8]

Pitfalls. Open-ended certificates; waiting for zero anxiety before any school contact; missing risk/safeguarding.^[1][8]