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Emotionally-based school avoidance (EBSA)

Emotionally-based school avoidance (EBSA)

Attending school has many benefits for children and young people, including having access to education; building confidence and self-esteem; learning to think critically and express themselves; spending time with friends; and developing relationships with adult role models (BJGP 2023. 73(734):414-415).

School absence has a negative impact on children and their families, and rates have increased following the COVID-19 pandemic. A significant proportion of absences relate to emotionally-based school avoidance (EBSA). This article explores what EBSA is, how it affects young people, and the role of primary care in supporting children and families who are struggling with attendance at school.

This article has been largely drawn from a review in BMJ Mental Health (BMJ Ment Health 2024;27:e300944). Other sources are cited where used.

This article was reviewed in June 2024.

EBSA refers to reduced attendance or non-attendance at school as a result of emotional factors or distress. This term is increasingly used in preference to the term ‘school refusal’ because it highlights that the child’s non-attendance is due to underlying emotional, mental health or wellbeing difficulties, rather than as an act of defiance or ‘refusal’ to attend.

EBSA may involve regularly missing whole days at school and prolonged periods away from school, and can also include:

• Not going to a classroom or not staying in class.
• Not attending some lessons.
• Avoiding some physical spaces or people.

EBSA is not a medical diagnosis, but it may be associated with a range of underlying problems, including social anxiety, generalised anxiety disorder, specific phobia, separation anxiety, depression and PTSD.

• EBSA results in missed schooling for around 1–5% of the total school population. An even greater proportion of children experience distress and aversion to school, but still manage to attend.
• Attendance statistics in England from 2023/24 (Pupil absence in schools in England, Office for Statistics Regulation, 2024) show that:
  • The overall absence rate of children from school was 6.7%. This is a decrease from 7.5% in 2022/23, but remains higher than pre-pandemic rates, which were consistently below 5%.
  • Most absences were due to illness.
  • 19.4% of pupils were persistently absent (missed 10% or more of school sessions). This is a decrease from 24.2% in 2022/23, but remains much higher than pre-pandemic levels (10.9% in 2018/19).
  • 2% were ‘severely absent’ (missing 50% or more of school), which has increased from 0.7% in 2016/17.

EBSA has significant negative consequences for children and their families, including:

• Lower educational attainment due to missing lessons. Even when managing to attend school, anxiety associated with EBSA may impair learning in the classroom.
• Increased risk of mental health problems.
• Difficulty with transitions, e.g. to secondary school.
• Problems with peers: fewer friendships and social withdrawal.
• Family conflict and relationship difficulties at home.
• Stress and frustration in parents and carers.
• Risky/criminal behaviour.
• Lower employment prospects.

EBSA typically arises from a complex interplay between predisposing factors and a precipitating event or change in the child’s circumstances. Risk factors for school non-attendance are summarised in the table below (School attendance and mental wellbeing Anna Freud National Centre for Children and Families, 2024):

Other factors that can influence school attendance (Back into school: new insights into school absence. Children’s Commissioner, 2022):

• Attending the first week of school is a strong indicator that a child will go on to attend regularly.
• Children who have an unauthorised absence (even for a day) in the first week of term are at higher risk of persistent absences: a rate of 25% of unauthorised absences compared with 2% in children who attended every day in the first week of term.
• Vulnerable children may be at greater risk: 33.6% of pupils receiving free school meals were persistently absent in 2021 compared with 20% of pupils not in receipt of free school meals.
• Prolonged school closures during the COVID-19 pandemic disrupted social routines and peer interactions, heightened feelings of isolation, and contributed to a breakdown in the relationship between many families and schools (BMJ Ment Health 2024. 27:e300944).
• The cost-of-living crisis has created further hurdles to attendance such as difficulties affording school uniforms or transport to school.

The varied risk factors and difficulties associated with EBSA mean that most children will need a multi-agency approach that involves education, health, social care and voluntary sectors.

Early intervention before EBSA becomes chronic or ‘entrenched’ is often important, but the lack of services in many areas can be a major barrier to accessing prompt and effective treatment.

A review of attendance interventions to improve school absenteeism found that, although the overall quality of evidence is weak and more research is required, the following have been found to be helpful (Attendance Interventions, Rapid Evidence Assessment; Education Endowment Foundation, 2022):

• Parental communication: providing information that increases awareness of the consequences of absenteeism, and targeting common misconceptions about the importance of regular attendance.
• Targeted parental engagement: discussions with parents about the reasons for low attendance, and collaboratively planning ways to support students and their families to overcome barriers to attendance.

Other treatment approaches include (BMJ Ment Health 2024. 27:e300944):

• Support for families to improve parenting skills, reduce parental stress, and reduce parenting behaviours that may inadvertently maintain or reinforce child anxiety and avoidance of school.
• Addressing family risk factors, particularly in primary school-age children.
• School-based interventions: these include adjustments to the school day and environment to facilitate a return to school, such as:
  • Providing safe spaces.
  • Temporarily reducing homework or other demands.
  • Implementing a flexible phased return to school.
  • Support for when anxiety is experienced at school, for example teaching anxiety management or relaxation techniques.
  • Referral for assessment of special educational needs.
  • Addressing peer relationship difficulties or bullying.
  • Improved home–school communication, which includes the school taking a non-judgmental approach and working in partnership with parents.

There was little evidence for family incentives/disincentives, mentoring or purely child-focused approaches (Attendance Interventions, Rapid Evidence Assessment; Education Endowment Foundation, 2022).

An article in the BJGP explored the role of primary care in supporting children and families with EBSA (BJGP 2023. 73(734):414-415). We often know families who may turn to us when they have concerns. We can explore factors affecting the child and the family, and issues at school (see table above). In particular, we have a role in:

• Encouraging parents and carers to speak to school staff about any worries their child may have, enabling them to work together to support the child and improve attendance.
• Discussing the health and wellbeing benefits from good school attendance, emphasising the importance of attendance for every child’s long-term outcome, while continuing to support the child and their family.
• Highlighting the importance of attendance in the first week of term (since failure to attend then is a marker for ongoing poor attendance).
• Identifying any underlying mental health difficulties and offering advice, including signposting to self-help/community support or referral to CAMHS if indicated.
• Supporting parents and carers, including assessing their mental health needs and offering evidence-based treatment where indicated.
• Making a risk assessment and acting promptly on safeguarding concerns if a child may be at risk of harm.
  • Homeschooling is not an inherent safeguarding risk, and can be effective and positive for many children. However, vulnerable children who are homeschooled can become hidden from view and lose protective factors such as regular contact with their teachers or access to free school meals; this means that safeguarding concerns may be less likely to be recognised.
• Supporting school attendance: consider making a practice policy to try and schedule routine appointments outside school hours to minimise time taken off school.

EBSA is not the same as a child who is being homeschooled, which is also known as elective home education.

Parents choose to educate their children at home for a variety of reasons. Some of these may overlap with the causes of EBSA, and, for some, EBSA may be the reason for elective home education. However, this will not be the case for the majority of children who are electively home educated.

The government has published guidance for local authorities (Elective home education: departmental guidance for local authorities 2019; Department of Education) which highlights that:

• Parents have a right to educate their children at home rather than sending them to school. The responsibility for provision of education lies with parents. Education does not need to follow the national curriculum, and children are not required to enter exams. Home education may involve using private tutors, attending support groups or part-time tuition, but there is no requirement to do so.
• The Government highlights that many children benefit from being educated at home. A parent may choose elective home education for many reasons, including:
  • Ideological differences, or wanting to provide education with a different basis from that found in schools.
  • Wanting to ensure that education is aligned with religious or cultural beliefs.
  • Being dissatisfied with the school system or the local schools in which a place is available.
  • Experiencing bullying at school.
  • Health reasons, particularly mental health difficulties.
  • A child’s unwillingness or inability to attend school, including school phobia.
  • Special educational needs, or a lack of suitable provision in the school system for those needs.
  • Disputes with a school about education, or the needs or behaviour of the child, sometimes leading to exclusion.
  • Other reasons that do not relate to school or education, e.g. using older children as carers for adults or younger siblings.

• There is no proven correlation between home education and safeguarding risk. However, local authorities continue to have the same safeguarding responsibilities for children educated at home as for other children.
• The risks of home education include that some children may not receive a suitable education, and that some vulnerable children may not be in a safe environment.  
• A child being educated at home may not be seen on a regular basis by professionals such as teachers, which means that safeguarding concerns could go unrecognised.
• Equally, some parents may feel that home education is protecting the child from significant risks in the school system such as serious bullying.

In primary care, it is helpful to understand the reasons that a family may choose home education, and this may guide us in offering support around mental health and overall wellbeing. We will not play a role in overseeing or evaluating the educational aspect of home education, but, in some vulnerable families, we may have an important role in safeguarding, which could involve liaison with local authorities and social services.

Emotionally-based school avoidance EBSA refers to reduced attendance or non-attendance at school as a result of emotional distress, and should be used in preference to the term ‘school refusal’. Absence from school is associated with many negative outcomes, including lower educational attainment, mental health problems and family stress or conflict. It is helpful to take a holistic approach to understanding the causes of EBSA, and consider a range of risk factors that may relate to the child, their family and the school environment. Our role in primary care includes: Encouraging children and families to engage with schools to improve attendance. Highlighting the benefits of school attendance, especially in the first week of term. Assessing for associated mental health difficulties. Signposting to self-help, community support or referral to CAHMS if indicated. Supporting wellbeing in parents and carers. Risk assessment and considering possible safeguarding concerns. Parents can choose to electively home educate a child for many reasons (which may or may not include EBSA), and this can be beneficial for many children. Home-educated children may be less likely to be seen regularly by professionals outside the home, potentially making them more vulnerable to safeguarding concerns going unrecognised. If you have safeguarding concerns about ANY child, it is important to take action and liaise with other agencies.

Useful resources for families: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Young Minds - school anxiety and refusal Not Fine in School (support for families with children experiencing school attendance barriers, providing peer support, empowerment and awareness) Square Peg (a social enterprise seeking to make change for children who struggle to attend school and their families) They are the Future - EBSA resources for parents Books Understanding and Supporting Children and Young People with Emotionally Based School Avoidance, Tina Rae (Hinton House Publishers, 2020) Overcoming School Refusal: a practical guide for teachers, counsellors, caseworkers and parents, Joanne Garfi (Australian Academic Press, 2018)