Early warning signs include crying during school hours, disruptive behavior designed to force school officials to send the child home, frequent attention-seeking behavior such as calling or texting one’s parents, frequent requests to use the restroom, go to the main or nurse’s or counselor’s office, or otherwise be excused from class, frequent somatic complaints such as stomachaches, headaches, nausea, and discomfort, frustration among youth with learning or developmental disorders, separation difficulties, social isolation, sudden changes in behavior or personality, sudden decline in grades or other academic performance such as homework, and test anxiety. These do not necessarily mean a child will start missing school, but they are often precursors. School-based threats are important to monitor as well.

Good schools are proactive about taking action when a child misses school on any given day, including immediately informing parents and doing what is possible to secure even partial attendance for that day. Good schools frequently convey the value of coming to school, have a good and safe school climate, and provide incentives for attendance. Instead of focusing only on a punitive approach such as referral to a juvenile court, good schools try to resolve the school attendance problem in-house and try to maintain a student's positive connection to school. Good schools also try to match the demographics of the faculty with those of the surrounding neighborhoods and provide substantial academic support.

Short-term effects include emotional problems, social disconnection from peers, falling behind in schoolwork, family tension, and possible financial difficulties if parents have to miss work or find alternate child care. Long-term effects if a school attendance problem is chronic and severe can include physical and mental health problems and school dropout. Students who drop out of school generally have less lifetime earning potential and other problems compared to those who graduate from high school.

Not all children with school attendance problems have anxiety and most probably do not. Many students become disconnected or disengaged with school starting in middle school when they struggle in a certain course, are disciplined at school, or have a substance use problem. Other kids skip school to be with their friends or do other fun things during school hours and are not particularly anxious. That said, even when a child has been out of school for some time for non-anxiety reasons, when it is time to reintegrate to school the child may often have a spike in anxiety or worry about what will happen when they return. Other students suffer more from depression than anxiety and this significantly interferes with school attendance as well.

Main first steps are to fully understand the school attendance problem and why it continues on a day-to-day basis. Given the urgency of many of these cases, an immediate plan is usually put into place that includes maintaining a regular morning routine, attending school even if part-time, completing academic work during the day even if not in school, staying in regular contact with school officials, and increasing supervision of the child. Later steps will be more therapeutic in nature and can include strategies for anxiety management, parenting approaches, and family communication and problem solving, among others.

We involve the school in all of our cases regardless of the child's age. We consult with school officials about what we can feasibly do with respect to our treatment procedures, accommodation plans, academic and attendance records, and school regulations. We typically communication with school counselors but our communications can also be with individual teachers or administrators. The best approach to solve these problems involves a "three-legged stool" that involves the therapist, parents, and school officials.

If school-based threats are the main reason for a student's attendance problem, then resolving the school-based threat takes priority and must be achieved prior to any treatment. Once the threat has been removed, then treatment can include processing that event, maintaining realistic thinking, and practicing safety procedures such as being with friends and letting adults know if another threat emerges.

Causes of school attendance problems and anxiety-based school refusal can be quite varied and often hard to pinpoint. Many risk factors occur in this population that include child, parent, family, peer, school, and community variables. As a psychologist, I focus on child and family dynamics but many cases also involve dealing with peer or school issues. We tend to focus more on what maintains or reinforces a child's unwillingness to attend school on a given day. Risk factors certainly differ from younger to older children; adolescents often become more disengaged with school in middle and high school, are more prone to depression and substance use, and can leave a school campus more easily than younger children, for example.

For younger children we stick to the basics when it comes to cognitive work, such as discussing their concerns and helping them to understand that the chances of something bad happening are low given that a certain event has not occurred before or has not occurred much before. We help them understand the connection between their emotions and their behavior if possible but usually focus on methods to help them feel less aroused as well as a gradual re-entry into school.

If a child has difficulty attending school for less than two weeks, then trying to have the child attend school for at least part of the day should be a priority if possible. Many children have difficult adjusting to school and it takes some time for them to feel comfortable there. If the problem lasts longer than two weeks, then seeking the counsel of a qualified therapist is recommended. Parents should also maintain close contact with school officials to see if there is a possible resolution to the attendance problem or to send academic work home so the child does not fall too far behind.

This is a good question and we just do not know the answer at this point. When children do go back to school full time there are likely to be many adjustments that will have to be made, including adherence to new health protocols, modified schedules, closed activities, and distancing. In addition, many students will have been off a normal schedule for many months, which may make a return to school especially difficult. Of course, many kids and parents have experienced mental health problems during this time as well. For now, keeping kids on as regular schedule as possible, including early morning rising and getting ready for school as if a normal day, will be important to help ease the transition.