ConditionChildren's health
School Absenteeism and School Refusal
School absenteeism is missing school, and it becomes chronic when a child misses 10% or more of school days (about 18 days in a US school year) for any reason. Common causes include illness such as asthma, anxiety and depression, bullying, learning difficulties and family problems. School refusal is a specific pattern in which a child is too distressed to attend, often with stomach aches or headaches on school mornings. Early, coordinated support from family, school and health providers helps most children return.
Also called: Chronic absenteeism, school avoidance, school refusal, emotionally based school avoidance, persistent absence
At a glance
- What it is
- Missing school frequently; chronic absenteeism is missing 10% or more of school days.
- Health causes
- Asthma, frequent infections, chronic pain, sleep problems, mental health conditions.
- Emotional causes
- Anxiety, depression, bullying, learning or social difficulties.
- School refusal
- Distress about attending, often with physical symptoms on school days.
- Help
- Rule out medical problems, treat anxiety (often with CBT), and plan a gradual, supported return.
When to get help
Call 911 or go to the ER
- A child or teenager talking about suicide or self-harm, or showing signs of having self-harmed: call or text 988 (US), or call 911 or your local emergency number
See a doctor within a day or two
- Sudden refusal to go to school with signs of abuse, bullying injuries or a major change in behavior
- Panic attacks, not eating, or not leaving the house for days
- Severe low mood, withdrawal or hopelessness for more than 2 weeks
Book a routine appointment
- Missing school frequently with stomach aches, headaches or vague illness that improve on weekends
- Increasing absences over weeks or months
- Learning, attention or social difficulties that make school distressing
- Asthma, sleep or other health problems causing frequent absences
Why attendance matters
Chronic absenteeism is linked to lower reading and math skills, falling behind, disengagement, and higher risk of dropping out. The American Academy of Pediatrics recognizes school attendance as a health issue, because poor attendance and poor health often feed each other. Even absences for illness add up.
Types of absenteeism
| Type | Description |
|---|---|
| Health-related | Absences for genuine illness, appointments or chronic conditions |
| School refusal (emotionally based) | The child is distressed by school; parents usually know where the child is |
| Truancy | Skipping school without parental knowledge, often linked to disengagement or other activities |
| School withdrawal | Parents keep the child home (for example, to care for siblings, or due to their own anxiety) |
| School exclusion | Suspensions or informal exclusions by the school |
Common causes
Physical health
- asthma, the leading chronic illness causing school absence
- frequent infections, especially in young children
- chronic pain (headaches, abdominal pain), migraine
- dental problems
- sleep problems and insufficient sleep
- chronic conditions such as diabetes, epilepsy, sickle cell disease and chronic fatigue syndrome
Mental health and emotional factors
- anxiety: separation anxiety in younger children, social anxiety, generalized anxiety and panic attacks in older children
- depression
- bullying and peer conflicts
- ADHD, learning disabilities and autism, which can make school stressful
- trauma, grief or family changes
Social and environmental factors
- unstable housing, transport problems or caring responsibilities
- family illness or parental mental health problems
- unsafe routes to school or community violence
- a negative school climate
School refusal: signs
- distress, tears or tantrums on school mornings
- frequent physical complaints (stomach aches, nausea, headaches, dizziness) on school days that improve once the child is allowed to stay home or on weekends
- begging to stay home, or calling home repeatedly from school
- avoiding specific situations such as tests, gym class or lunchtime
- sleep difficulties on Sunday nights
The longer a child stays out of school, the harder returning usually becomes, because avoidance reinforces anxiety.
How health professionals help
- Medical assessment: a primary care doctor checks for physical causes of symptoms and treats any illness. Recurrent stomach aches or headaches without a medical cause are common with anxiety but should still be assessed.
- Mental health assessment: screening for anxiety, depression, ADHD, autism, learning problems and trauma.
- Collaboration with the school: sharing information (with consent), identifying triggers, and planning support.
Treatment and support
- Cognitive behavioral therapy (CBT): the best-supported treatment for anxiety-based school refusal. It teaches coping skills and uses gradual exposure to school.
- Gradual return plan: starting with part of a day or favorite classes, with a trusted adult at school and a safe space, then increasing.
- Parent support: clear, calm routines; avoiding making home more rewarding than school during school hours; praising attempts.
- School accommodations: under a 504 plan or IEP in the US, for example adjusted schedules, extra time or support for learning difficulties.
- Addressing bullying promptly and firmly.
- Medication: SSRIs may help moderate to severe anxiety or depression alongside therapy.
- Managing health conditions: good asthma control, sleep routines and pain management.
Prevention
- regular sleep schedules and limiting late-night screens
- keeping children home only when genuinely unwell (for example fever, vomiting or diarrhea)
- staying in touch with teachers about concerns early
- teaching children to name and manage worries
- keeping vaccinations up to date to prevent illness
Frequently asked questions
What is chronic absenteeism?
Chronic absenteeism is missing 10% or more of school days for any reason, excused or not. In a typical US school year of 180 days, that is about 18 days. It is linked to poorer learning and health outcomes.
What is school refusal?
School refusal is when a child experiences significant distress about going to school and avoids it, often with physical complaints such as stomach aches on school days. It is usually driven by anxiety, depression or difficulties at school rather than defiance.
How do I help my child who refuses to go to school?
Talk calmly to understand the cause, see your child's doctor to rule out medical issues, and work with the school on a gradual return plan. Cognitive behavioral therapy is very effective for anxiety-related school refusal. Avoid letting absences become long, as returning becomes harder.
Can anxiety cause stomach aches before school?
Yes. Anxiety commonly causes stomach aches, nausea, headaches and other physical symptoms, especially on school mornings. If symptoms regularly disappear on weekends and holidays, anxiety is a likely factor, though a doctor should check for other causes.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Pediatrics: Policy Statement: The Link Between School Attendance and Good Health
- US Department of Education: Chronic absenteeism data and guidance
- American Academy of Child and Adolescent Psychiatry: School refusal (Facts for Families)
- CDC: Healthy schools: absenteeism
- Attendance Works: Chronic absence resources