Adolescent with Anxiety and School Refusal
A 15-year-old boy is brought by his mother due to 2 months of school refusal. He reports feeling anxious and nauseous every morning before school and has missed 15 days of school. He has no friends and spends most of his time playing video games. His grades have dropped. He denies suicidal ideation, self-harm, or substance use. He is physically healthy. His mother is worried and wonders if he needs medication. The clinic has a therapist available for counseling and can coordinate with the school.
1. What is your diagnostic assessment, and what factors may be maintaining his anxiety?
Read the worked answer
Assessment: generalized anxiety disorder or social anxiety disorder vs school refusal related to anxiety. Rule out depression, bullying, learning disorders, and physical illness. Maintaining factors: avoidance (missing school reduces anxiety temporarily but reinforces fear), social isolation (lack of friends, excessive gaming), family accommodation (mother allowing him to stay home), and academic stress. His physical symptoms (nausea) are consistent with anxiety. Denial of suicidal ideation is reassuring but should be reassessed.
2. What treatment plan would you recommend, and how would you involve the school and family?
Read the worked answer
First-line: cognitive behavioral therapy (CBT) with a therapist, focusing on gradual exposure to school and anxiety management. Family involvement: psychoeducation, reduce accommodation, establish a consistent morning routine, and set limits on gaming. School coordination: meet with school counselor to develop a re-entry plan, identify a safe person at school, and address any bullying. Medication (SSRI) is not first-line but can be considered if therapy is insufficient or if symptoms are severe; discuss risks and benefits with the family. Follow-up in 2-4 weeks to monitor progress and school attendance. If no improvement, consider psychiatric referral.