School absenteeism spiked during the COVID-19 pandemic and shows little sign of returning to pre-pandemic levels. In England, which is now in the midst of a widely publicised surge in absenteeism, overall absence rates had remained fairly steady following a decrease from 2006/2007 when pupil-level data on attendance were first collected.1 2 Unauthorised absences and severe absenteeism (defined as missing >50% of academic sessions) were, however, on a gradual upward trend prior to 2019–2020.3 During the 2022/2023 academic year, the overall absence rate in English schools was 7.5% compared with ~5% pre-pandemic, while the rate of persistent absenteeism (defined as missing >10% of academic sessions) was 22.3%, approximately double the pre-pandemic rate. Increased rates of absenteeism have been reported in both primary and secondary settings, especially in state-funded schools.4 The rise in school absenteeism post-pandemic is not confined to English schools but has also been observed globally. UNESCO estimated that 10.9 million primary and secondary students worldwide were at risk of not returning to school after the pandemic.5

A significant component of the uptick in missed schooling can be accounted for by rising cases of emotionally based school avoidance (EBSA).6 In this article, we define EBSA and outline its impacts. We consider how psychological and contextual factors during the pandemic may help to explain the recent increase in school absenteeism and discuss priorities for new interventions to address this concerning trend. We focus on the educational system and statutory context in England but acknowledge that many of the points raised are relevant to other educational contexts globally.

What is EBSA and what is the cost of leaving it untreated?

EBSA refers to reduced attendance or non-attendance at school where the avoidance is driven by emotional distress. EBSA does not constitute a psychiatric diagnosis in its own right but often co-occurs with diagnoses of anxiety and/or mood disorders.7 EBSA commonly emerges during primary school and educational transitions (e.g. when starting secondary school) represent particularly high-risk periods. EBSA results in missed schooling for an estimated 1%–5% of the total school population; an even larger population of children experience distress and aversion to school but still manage to attend.8

EBSA has significant negative consequences for children and their families. Most obviously, absence from school leads to a loss of education and thus impedes academic attainment. Only half of pupils with an attendance rate below 90% (i.e. children defined by the UK Department for Education as persistently absent) achieve the expected standard in reading, writing and mathematics at the end of Key Stage 2 (i.e. when aged 10–11 years) compared with 71% of pupils with >99% attendance.9 Even when children are managing to attend school, the anxiety associated with EBSA may impair learning in the classroom.10 11 Lower attendance is further associated with an increased likelihood of experiencing mental health problems, fewer friendships and poorer employment prospects.12 Many caregivers also report stress and frustration when managing EBSA.13

Risk factors in the post-pandemic context

EBSA arises from a complex interplay between predisposing factors and a precipitating event or change in the child’s circumstances. Relevant contributing factors can originate from the school, family and/or peer environments, and may include bullying, academic pressures, parental mental health difficulties and changes in family dynamics (see figure 1). Intrinsic child characteristics, such as separation anxiety, special educational needs and low self-confidence, may also predispose children to EBSA.12

Figure 1

COVID-19-related psychological and contextual factors have acted to amplify pre-existing school, family and child-related risk factors for emotionally-based school avoidance (EBSA). EBSA is maintained by negative reinforcers including wanting to reduce distress associated with attending school . Positive reinforcers of EBSA include attention from significant others and access to pleasurable reinforcers outside of school (Kearney & Silverman, 1990). EBSA is associated with a range of negative educational, health, social and economic outcomes.

There is evidence that psychological and contextual factors operating during the pandemic and beyond have converged to create the ‘perfect storm’ of conditions, amplifying known risk factors for EBSA and reducing access to support services.14 Prolonged school closures heightened feelings of isolation and disrupted social routines and peer interactions. These conditions contributed to worsening mental health for children and their parents, which in some cases will have persisted once schools reopened.15 Adverse mental health impacts have been most sustained for children with special educational needs and disabilities, neurodevelopmental disorders, fewer close friendships and those living in families with lower incomes and higher parental stress.16 On the other hand, school closures provided a welcome relief from the stresses of school for some children, including those with pre-existing EBSA. For these children, returning to school may have been particularly challenging because school closures will have reinforced their avoidance of school.13

Furthermore, research by our group and others indicates a fundamental breakdown in the relationship between many families and schools, which is known to be an important predictor of absenteeism.12 13 17 Social distancing restrictions contributed to home–school relationship difficulties by restricting regular opportunities for in-person (often impromptu) contacts between families and school staff.15 At the same time, parental attitudes toward daily school attendance have perceptibly shifted. Against a backdrop of school days lost to lockdowns and recent teacher industrial action, some parents no longer view daily attendance as essential but instead view school attendance as one of several competing demands in their child’s daily life.17 The current cost-of-living crisis, precipitated in part by the pandemic, is likely to have created further hurdles to attendance (e.g. difficulties affording school uniforms and transport to school).

Priorities for interventions for EBSA in the post-pandemic context

By convention, the UK Department for Education stipulates that absence due to a (mental) health-related reason should be recorded as ‘authorised’. In practice, however, absences caused by EBSA are commonly recorded as unauthorised and can trigger a variety of punitive measures. Such statutory responses are typically viewed as ineffective and antagonistic by parents and may include referral to the local authority for investigation and/or parental fines.17

The varied interacting risk factors for EBSA necessitate a multi-component approach, which cuts across education, health and social care, and voluntary sectors. A recent review of attendance interventions found little compelling evidence for family incentives/disincentives, mentoring and solely child-focused approaches. More promising evidence was identified for programmes that centred on parental engagement and communication, while also attending to one or more psychosocial risk factors.18

Where EBSA is entrenched, Child and Adolescent Mental Health Services (CAMHS) can offer psychological interventions such as cognitive–behavioural therapy (CBT) to address underlying anxiety problems. This usually involves exposure work with children and/or parent-focused sessions to address ‘family accommodations’ (i.e. repeated reassurance-giving that can maintain anxious avoidance). However, there is mixed evidence for CBT’s effectiveness in improving school-related anxiety and attendance.19 Moreover, gaining access to specialist psychological interventions can be frustratingly difficult. Rising clinical thresholds, compounded by the pandemic, have effectively rationed publicly funded treatment to the extent that nearly 250 000 children (32% of all referrals) were turned away or redirected by NHS CAMHS during the 2021/22 financial year.14

Consequently, there is a need for pragmatic, contextually-relevant interventions that complement existing provision and can be accessed rapidly before EBSA becomes chronic. There is a strong argument for early intervention that does not impose strict absenteeism criterion as a condition of access, given that school-related anxiety can impair functioning even before absenteeism takes root. Parent engagement is key and this may necessitate specific adaptations, both to programme content and delivery formats, to ensure equitable outcomes for diverse families. For example, highly structured, time-intensive parenting interventions appear less effective for multiply stressed families with low incomes and parental mental health problems.20 Specific content may need to address low self-efficacy, systemic/structural barriers to effective parenting, parental stress and well-intentioned parenting behaviours that can inadvertently maintain child anxiety and avoidance of school, alongside exploring negative prior experiences of services and encouraging the building of more trusting, collaborative relationships with providers.21 Content should also reflect the developmental stage of the child. Interventions delivered primarily to parents and with a focus on family-level risk factors may be most appropriate for tackling EBSA in primary school-aged children given the central influence of parents in younger children’s school lives.

The school system is another important setting for EBSA interventions, particularly in the context of ‘whole-school’ approaches that place child mental health and well-being at the heart of educational provision.22 Relevant interventions may involve adjustments to the school day and environment, with these being of particular importance for children with special educational needs, such as providing safe spaces, temporarily reducing homework and implementing flexible-phased returns to school. Support for anxiety may include the teaching of anxiety management techniques (e.g. relaxation training) and other evidence-based psychological approaches. Schools may refer children and parents for whole family support and further assessment of special educational needs where indicated. Addressing additional relationship and/or bullying issues contributing to EBSA may involve targeted and whole-school interventions which build social skills, increase pupil social capital and foster rapport between pupils, teachers and other trusted adults (e.g. mentoring schemes, peer mediation, bystander defender training).23 Positive home–school communication, characterised by a non-judgemental approach and partnership working with parents, is also important for the effective resolution of EBSA and often identified as a key area for improvement by parents.13

To enhance scalability and address the acknowledged ‘need-to-access gap’ in child mental health and social care, there is also a strong case for developing streamlined interventions that are situated outside of professional-led settings.24 Online interventions, particularly when accompanied by synchronous (non-specialist) human support, can be as effective as in-person formats.25 Even very brief, focal interventions (i.e. those that target a small number of specific mechanisms) can significantly improve child mental health symptoms, including anxiety problems.26 27 Treatment effects may be slightly smaller compared with traditional multi-session treatments but there are significant advantages in terms of improved reach and accessibility.26 For example, recent studies have demonstrated the feasibility and acceptability of brief parent-led interventions that target parenting factors known to influence the development and maintenance of child anxiety.27 ,28 Peer-led models (e.g. where a fellow parent acts as an intervention ‘facilitator’, ‘coach’ or ‘guide’) warrant consideration as a method for delivering evidence-based community-based parenting interventions. Such peer-led delivery models appear to be particularly effective for engaging disadvantaged families.29 Moreover, peer-led approaches are consistent with the global literature on ‘task-sharing’ of psychosocial interventions in low-resource settings, with mounting evidence that effectiveness does not depend on the involvement of highly qualified practitioners.30

Conclusion

Regular school attendance is critically important for children’s education, well-being and life prospects, but there is a downward trend in attendance rates for enrolled pupils in England and internationally. For a substantial number of children, persistent absenteeism is related to EBSA. The reasons behind the rise in EBSA are multifaceted and there is compelling evidence that the pandemic and its sequelae have acted to amplify known risk factors. We need more accessible, resource-efficient interventions that can be delivered at scale as part of a multi-sectoral approach to tackling the rising toll of absenteeism.

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