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Supporting Children with Medical
and Mental Health Needs at School


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Emotionally based school avoidance (EBSA) is when a child or young person experiences extreme difficulty in attending school.

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Absence from school can be for long periods and is known to parents/carers. EBSA is generally complex and is best supported through early intervention. In the UK it is believed EbSA affects between 1-2% of the school population. It is more prevalent around transition to secondary school. It equally affects boys and girls. (1)


Many children and young people may at one time or another say they don’t want to go to school for a specific reason, such as falling out with a friend or not completing homework on time. EBSA is different. It’s persistent non-attendance where the reason for absence is complex and not always immediately evident to the family or school.

EBSA is often referred to as ‘school refusal’. This term is unhelpful as it suggests the issue is located solely with the child or young person. It fails to describe the interplay between school, home and child, all of which can contribute to a child with EBSA finding it difficult to attend school regularly.

There are some features that may make a child or young person more likely to experience EBSA than others. These are generally referred to as risk factors.

Risk factors include:


Bullying, transition to secondary school, the structure of the school day, academic pressure, peer and staff relationships.  


Temperament, poor self-confidence, physical illness, specific ages (6-7, 11-12 13-14), Special educational needs, ASD (unsupported/unidentified), traumatic experiences or events.


Separation and divorce, parental physical and or mental health, loss and bereavement, high levels of family stress.

Reasons for non-attendance are generally related to four key areas: (2)

  1. Avoiding uncomfortable feelings of anxiety experienced when in school
  2. Avoiding stressful situations such as academic demands, social pressures or aspects of the school environment
  3. Needing to reduce separation anxiety from a significant adult
  4. To participate in activities such as shopping, playing games with a significant adult


Early intervention is crucial. The longer the problem remains the poorer the outcome. Early identification of EBSA can be difficult. Children and young people can find it difficult to articulate their feelings and distress about attending school in a way that school and family can understand. How a young person presents at home and in school may also be different. Sometimes this can lead to feelings of blame resulting in school or family feeling defensive or anxious. 

It is important that all perspectives are shared and listened to. Views need to be respected and differences acknowledged.

Initially looking at behaviour rather than a cause can be helpful. Every child and young person experiencing EBSA will present differently.

After an initial assessment of the situation a plan needs to be drawn up that is devised and agreed upon by the team supporting the child or young person. This may include an educational psychologist, the SENDCO or identified school staff member, family members and the child or young person. The plan will be unique and will focus on the strengths and challenges faced by the child or young person.

Supporting students with Emotionally Based School Avoidance

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Identification and Planning

  • Early identification is crucial. Look for attendance patterns, changes in behaviour, and changes in family circumstances. Ask questions to find out what is happening for the child or young person.
  • Listening carefully to understand, don’t make assumptions based on the experience of other students.
  • Set realistic goals. Overambitious plans are likely to fail.
  • Plans work best if they are gradual and build in actions for when things aren’t working.
  • Working collaboratively is important. Child or young person, Family and school all working together with the child at the centre.
  • Good communication is vital. Home-school communication is important when things are going well and when they’re not.
  • Accept there will be good and bad days but each day is a fresh start.

Interventions and Strategies

  • Assess, Plan, Do, Review. This cycle will help structure support.
  • Active teaching of skills to manage anxiety, such as relaxation, breathing, distraction.
  • Gradual re-exposure to the school environment, starting with least feared to most feared spaces. This will be individual to each child and young person (For example, standing outside a closed school building up to being in the dining hall.)
  • Agreed timetables, this could be part-time initially.
  • Agree and put the right support in place. This may include, an identified staff member, a time out card, access to a quiet space.
  • Teaching social skills may help some children and young people managed social situations that create stress and anxiety.
  • Use of role-playing to practice responding to questions about why they’re been absent or are attending school part-time.
  • Agree on times and activities for the child/ young person to do with a parent or family member.

 Whole School Systems

  • Mental health support for individual children and young people works best when embedded in whole school systems that promote wellbeing and good mental health for all members of the school community. See our page on A Whole School Approach to mental health.

More Information

Information and Advice for parents & carers from Young Minds

Animation from Angstvoordeschoolpoort This short film wants to give you a perspective of a young student who is struggling with school attendance.
Courtesy of

Understanding Persistent Absence from School This webinar recording from Excluded Lives, a research project based at the University of Oxford presents current data, research findings and discussion from groups involved in better understanding the causes of EBSA.


(1) King, N. & Bernstein, G. (2001). School Refusal in Children and Adolescents: A Review of the Past 10 years. (Journal of American Academic Child Adolescent Psychiatry) 2001 Feb:40(2):197‐205.

(2) Lauchlan, F.(2003)  Responding to Chronic Non-attendance: A review of intervention approaches
(Educational Psychology in Practice ) 2003 June 19(2):133-146

Understanding School refusal: a handbook for professionals in education, Health and Social Care. Jessica Kingsley, London, UK Thambirajah M,S., Grandison K.J., and De-Hayes L. (2008) 

Kearney, C & Albano, A. (2018) When Children Refuse School, Oxford University Press
Maynard, B. etal (2015). Treatment for School Refusal Among Children and Adolescents: A Systematic Review and Meta-Analysis  (ResearchGate)

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