Chronic absenteeism had been growing as a problem even before pandemic-related school closures disrupted the academic and social lives of American students. Despite the widespread relief felt by parents and the school community when there was a return to in-person learning, however, the number of students who chronically miss school continued to increase in the post-pandemic years. As reported in March 2024 by the NY Times, chronic absenteeism increased from 15% of public school students in 2019 to 26% of students in 2023. No area of the country or student demographic has been immune from this troubling trend.
Understanding School Refusal Behavior
Students are considered chronically absent when they miss at least 10% of the school year, or approximately 18 days. There are two primary sub-types of absenteeism, truancy and school refusal/avoidance. Truant students are typically disengaged and are seeking rewards outside of the school environment. They might exhibit rebellious, and at times even antisocial behaviors. School absences tend to be hidden from parents and generally are not accompanied by anxiety or emotional distress of any kind. Interventions for truancy focus on behavior modification techniques that employ both rewards and penalties, and on efforts to increase students’ school engagement.
School refusal behavior (also known as school avoidance), on the other hand, is largely an anxiety-based condition. It is not a psychiatric diagnosis per se, but rather it is a complex syndrome influenced by temperament, genetics, cognitive factors, plus family and school environments. It affects both boys and girls and can involve an unwillingness to attend school at all, and/or an inability to remain in school for the entire day. The average age of onset is between 10 and 13 years old, and it often occurs after a precipitating event such as a parent’s illness, a bullying incident, a move to a new home or school, a death in the family, or a prolonged absence from school for any reason. Up to 56% of school avoiding youngsters have a primary diagnosis of anxiety, including generalized anxiety, separation anxiety, or social anxiety, but avoidance can also be a manifestation of and/or co-occur with other significant mental health disorders including depression, bipolar disorder, or post-traumatic stress disorder (PTSD). Intervention must begin with a careful assessment of contributing factors followed by the application of evidence-based behavioral and mental health strategies.
Since the pandemic, a third category of chronically absent students has become more prominent: those whose families are navigating financial, safety, childcare, and/or transportation challenges that consistently interfere with a child’s school attendance. These might include older children being needed at home to care for younger ones while a parent works, or students who live in unsafe neighborhoods and don’t have access to reliable transportation. Interventions for this type of absenteeism must involve practical, community-based outreach and solutions.
Early intervention is crucial so recognizing the signs of school refusal is important since signs can appear a year or more before a pattern of refusal becomes entrenched. These signs can include frequent complaints of physical symptoms (like headaches or stomach aches), tantrums or extreme distress on nights before a school day, excessive worry about going to school, reluctance to return to school after a long weekend or extended break, frequent complaints about teachers or peers, and/or frequent requests to leave school early.
Chronic v. Acute School Refusal Behavior
School refusal can be acute or chronic. Acute episodes usually last for two weeks or under and typically have a distinct triggering event. Such events might include the death of a family member or a beloved pet, the illness of a parent, a bullying incident at school, a failure (or perceived failure) in academics or a valued activity such as sports, rejection by a peer, etc. Interventions should be swift and involve teachers and parents collaborating to enhance incentives for going to and staying in school for the entire day. Frequent validation of the student’s distress, along with extra support and reassurance, should be provided. School personnel and parents can encourage the student to share thoughts and feelings about the triggering incident and help the student practice specific stress management and self-regulation techniques.
Chronic school refusal usually suggests an underlying mental health concern such as anxiety or depression, although these mental health issues may be inextricably linked to learning disorders or neurodevelopmental issues (e.g., ADHD, autism spectrum) that can lead children from an early age to conclude that they are “different” and/or “less than”. Interventions for chronic school refusal generally require a highly structured plan for gradual exposure to the academic and social demands of the school environment. This exposure therapy must be coupled with considerable empathy and active treatment of the student’s mental health issues, e.g. cognitive behavioral therapy (CBT) for tolerating anxiety and challenging distorted thinking, along with strategies for regulating emotion such as mindfulness practice. Family therapy is often required as well to address ways in which worried parents might be inadvertently reinforcing avoidance behavior, and medication should be considered for students with moderate to severe mental health symptoms.
Common triggers and risk factors
There are many factors that contribute to the development and maintenance of school avoidance, but researchers Kearny and Albano highlight four primary reasons that students avoid school:
- To avoid school-related stimuli or situations that cause discomfort or anxiety (e.g., noisy cafeterias, crowded hallways, taunting by bullies, difficulty with schoolwork because of learning differences, increased academic workload, etc.)
- To avoid evaluative or social situations related to school performance (e.g., tests, public speaking, athletic or music performance, etc.)
- To receive attention from parents or caregivers (e.g., related to separation anxiety or because a child fears for the well-being of one or both parents at home, or feels needed by a parent, etc.)
- To seek tangible rewards at home that are more desirable than those that are available in school (e.g., access to video games, the ability to sleep in, working at a paying job, socializing with non-school friends, etc.)
The most effective intervention plans target each factor that is relevant for a given student. For example, gradual exposure and desensitization are relevant for school-related anxiety; social skills training and cognitive-behavior therapy can address social anxiety; trauma-focused interventions are necessary for students who have experienced bullying or other family-based or community traumas. The manipulation of incentives is necessary so that students are rewarded for school attendance rather than for staying home. Accomplishing this latter task can be especially difficult for some parents but their cooperation is essential to making the home environment (during the school day) as boring and unpleasant as possible (e.g., no access to games, toys, social media, staying in bed, or having fun one-on-one time with a parent). Parents also need coaching on how to redesign both night-time and morning routines to facilitate school attendance and on how to set appropriate boundaries for those children who might feel it is their job to take care of parents or to otherwise be involved with adult concerns.
Besides the mental health and family-oriented strategies described above, school professionals must intervene decisively to address bullying and other safety issues if these are contributing to a student’s school refusal. For students who express that they are overwhelmed, teachers and administrators might consider whether academic or other demands on a given student are too high and/or whether academic supports need to be implemented.
Impact on Academic and Social Development
One only needs to consider the ongoing aftermath of the pandemic to understand the negative impact of school refusal. Some of the common negative effects include:
- Learning loss and the accompanying impact on self-esteem and school connection.
- Social isolation and the disruption of social skills development, including communication skills, the capacity for conflict resolution and empathy, and the ability to self-regulate during in-person interactions with others.
- Increased family conflict, both parent-child and sibling-sibling, as the ongoing fights about school attendance deplete the family’s emotional resources and disrupt family routines.
- Increased mental health symptoms. Even though mental health difficulties often contribute to the beginnings of school refusal, they are also exacerbated by extended school refusal as typical developmental processes are interrupted. In addition, research has demonstrated that anxiety is essentially a disorder of avoidance – avoidance increases anxiety in the long run even though it may provide temporary relief in the moment.
- Increased high-risk behaviors can fill the time that would otherwise be spent in school. These include unsafe internet activities (e.g., connecting with strangers online and then meeting them in person) and drug/alcohol use that may serve as a diversion from boredom and/or to reduce anxiety or other unpleasant emotions.
How Can Children Overcome School Refusal?
Fortunately, there are a variety of evidence-based strategies to help students overcome school refusal. These interventions include cognitive behavioral techniques to help students gradually face and become desensitized to their fears and to tolerate uncomfortable emotions, and to learn adaptive social skills; parent coaching to ensure that incentives are aligned with school attendance and to create and maintain home-based rules and routines; and school-based interventions to create a safe, welcoming environment and to provide the academic and mental health supports needed by uneasy students.
Early Detection Benefits
It is critical to be vigilant about the early signs of school avoidance, before a child’s anxiety feels insurmountable and unhealthy behavior patterns become entrenched. As with most mental health problems, early intervention is associated with better outcomes. It reduces the time that affected individuals will suffer, minimizes school disruption and learning loss, prevents serious gaps in social development, and reduces family stress and dysfunction.
Problem behaviors associated with school avoidance often begin the night before a school day, with a child expressing anxiety, asking to stay home, or complaining of illness. On a school morning a student might refuse to get out of bed or might move so slowly that she misses the bus. While in school early signs of school refusal might be missing classes, frequent visits to the nurse’s office, or frequent requests to call a parent or to go home early.
4 Effective Interventions for Addressing School Refusal Issues
Cognitive Behavior Therapy (CBT)
Cognitive Behavior Therapy (CBT) approaches have become the gold standard of treatment for many mental health disorders. There are many different strategies that fall under the heading of CBT, some directly aimed at modifying behavior, some at challenging unhelpful thoughts and beliefs, some to regulate emotion and body sensations (e.g., mindfulness and relaxation techniques), and some to improve communication and other social skills. Studies have shown that approximately 70% of children respond positively to CBT when used to address school refusal.
Gradual Exposure
Gradual exposure is another behavioral technique that specifically helps individuals approach feared things or experiences (e.g., snakes, air travel, elevators, etc.) while tolerating and managing the accompanying anxiety. It has been used extensively to help individuals with specific phobias or those who are struggling with obsessive-compulsive disorder (OCD). In treating school refusal, gradual exposure involves everything from helping a student become accustomed to being near or in the school building (in more severe cases of school refusal) to gradually increasing the hours per day that a student is expected to be in school and attending mainstream classes.
School-Based Interventions Involving Mental Health Professionals
There are also school-based interventions involving mental health professionals that are needed to help an anxious child adapt to the school environment. These interventions typically involve a collaboration between educational professionals and mental health providers and are often documented in an Individualized Educational Plan (IEP) that spells out accommodations and specific resources (academic and otherwise) that can help a student overcome learning and mental health challenges. Some students may require alternative educational programs that provide an in-school or out-of-district environment within which a student can safely re-engage with schooling. The goal of these programs is to help students ultimately re-engage with a mainstream school setting.
In addition to IEPs and alternative educational programs, schools that adopt SWPBIS behavior management programs support school avoidant youngsters by increasing their sense of belonging and security. For example, SWPBIS programs can include mentorship programs, buddy systems, and/or small group activities to foster both peer-to-peer and student-teacher connections that can help school refusing students engage more fully in school life.
Established Routines and a Structured Home Environment
Family-based interventions include the development of established routines and a structured home environment. Homes that have consistent schedules and clear rules provide a sense of safety and security for children, and the adherence to home-based schedules provides predictability and mirrors what is expected at school.
Parent coaching helps parents learn how to empathically support their children without inadvertently reinforcing avoidance behaviors and how to consistently apply consequences and manage contingencies. Family therapy can help increase mutual respect and understanding and improve communication skills.
Why Consider a Collaborative Approach to Prevent School Avoidance?
Perhaps it is clear to the reader at this point that the professionals at ESS endorse a collaborative, multi-pronged approach to the complex problem of school avoidance. There are so many pieces of the puzzle to consider, and it is unlikely that any one stakeholder alone can achieve success. With open communication and collaborative problem solving, parents, school professionals, mental health providers, and struggling students can become partners to overcome school avoidance.
How Stakeholders Can Aid Students Experiencing School Refusal
Stakeholders can aid students experiencing school refusal by joining forces. The role of educators and school administrators is to create an inclusive, welcoming, and safe environment and to swiftly respond to bullying incidents and other unsafe conditions. School personnel who actively contribute to a school’s SWPBIS are also instrumental in helping school refusing students. By consistently teaching, modeling, and re-teaching school rules and expectations they provide each student with a blueprint for positive behavior.
Role of Mental Health Professionals
Both school-based and community-based mental health professionals offer expertise in assessment and intervention strategies and can consult with teachers and other educational staff about classroom level and individual techniques to address school refusal. Onsite school counselors can offer as-needed and urgent services to support students when their anxiety spikes and they feel unable to remain in school. The ability to tolerate discomfort without running away teaches children important lessons about themselves – that they can carry on with school and other activities despite emotional distress.
Role of Families
Finally, as mentioned above, parents, caregivers and other family members play a critical role in helping students overcome school avoidance. They can help teachers understand family stressors and dynamics, can implement and maintain family routines and rules, and can offer plenty of empathy, positive feedback, and tangible rewards to support a child’s school attendance.
Evaluating and Maintaining the Effectiveness of Interventions for Students
As with all school-based initiatives, successful outcomes depend on data collection, the articulation of measurable goals, and on regular monitoring to alert stakeholders about both progress and the need to adjust strategies that are not delivering desired results. Teachers and aides must be offered initial training and ongoing consultation about how to implement classroom-based strategies, and on how to monitor a student’s in-school participation and distress levels. Frequent communication among parents, teachers, mental health professionals, and the student can ensure that progress is recognized and that barriers to success are addressed.
School refusal is a complex problem that neither develops nor resolves overnight. Long-term maintenance strategies include continued communication, periodic re-evaluations of the student, and transition planning well in advance of a move from one level of intervention to another, especially if the student is moving from an alternative education program to a mainstream classroom.
Address School Refusal Behavior Through Proven Interventions
School refusal is a thorny problem but fortunately there are evidence-based strategies to help students and families who are struggling with the problem. ESS offers various levels of onsite mental health support within school districts, with an emphasis on Tier 2 and Tier 3 MTSS programs to help students with moderate and severe mental health symptoms. Professional development programs are also available to help school professionals develop necessary behavior management and student support skills.
We encourage you to learn more about ESS and to request a meeting with one of our clinical specialists to find out how we might support your school-based mental health efforts.
FAQs About School Refusal Interventions
What can a parent do if a child refuses to go to school?
First, talk to your child and ask what has made it so difficult for her to attend school. Ask about academic pressure, bullying, fear of failure, trouble with peers, etc. Then talk with her teacher and the principal to determine whether they are aware of school circumstances that might be affecting your child. Consult the school counselor or psychologist as well and work as a team to come up with an initial plan to help motivate her to come to school.
What are the IEP goals for school avoidance?
Typical IEP goals to address school avoidance include enhancing a student’s self-regulation skills, fostering positive relationships with teachers and peers, building communication skills, offering academic support where needed, and improving problem-solving skills. Each IEP is customized to the specific student and his needs.
Is school refusal a disability?
Many children who refuse school have an underlying mental health condition or learning issue and these conditions clearly meet the criteria for a disability.
What are school-based interventions for school refusal?
School-based interventions for school refusal can include the creation of an IEP or 504 plan that provides for learning and/or mental health accommodations and interventions. Other interventions might include school-based mental health individual or group treatment for anxiety or depression, and special incentives/rewards for school attendance.
Resources:
Why School Absences Have ‘Exploded’ Almost Everywhere – The New York Times
Strategies to Help Children Overcome School Refusal — Thriving Minds
School Avoidance 101: Assessment Scale & Parent Resources
What Is School Refusal Treatment Plan? – Moriah Behavioral Health
Ending the Battle: Essential Interventions for School Refusal – Bridge Care ABA
