A Clinician's Guide to School Attendance Difficulties

The Scale of the Problem

There's a vast gap between clinical definitions and the reality of chronic absenteeism.

Focusing only on the 1-5% with clinically-defined school refusal [1] misses the "40%+ of students" who are chronically absent and disengaged in Australia [2].

Decoding the Language

Understanding the terminology is the first step to effective assessment.

School Refusal / EBSA

Child-motivated non-attendance driven by "severe emotional distress". Parents are aware and typically trying to secure attendance [3].

Truancy

Deliberate, unauthorized absence "concealed from parents", often associated with antisocial behavior and a lack of emotional distress about missing school [1].

"School Can't" / School Distress

A neurodiversity-affirming perspective that reframes the issue as a "physiological inability to cope" with overwhelming distress, not a volitional choice [4].

Exclusion / Withdrawal

Absence due to school-initiated (suspension/expulsion) or parent-initiated (withdrawal to homeschool) actions, often following prolonged periods of distress.

The 'Why' Behind the 'No': Kearney's Functional Model

This foundational model assesses the purpose the behavior serves for the child [1].

Function 1: Avoidance

To avoid school-related situations that cause general distress, anxiety, or depression.

Function 2: Escape

To escape specific aversive social or performance situations at school (e.g., bullying, tests).

Function 3: Attention-Seeking

To gain attention from significant others, such as parents or family members.

Function 4: Tangible Rewards

To pursue tangible rewards outside of school (e.g., sleeping in, playing video games).

It's Not One Thing: A Multi-Systemic View

Attendance difficulties arise from a complex web of interacting factors across a child's entire world, as framed by Bronfenbrenner's bioecological model.

Individual
Child

Community & Society

Support services, safety

School Environment

Bullying, academic pressure

Family & Home

Parental health, conflict

The Neurodiversity Lens: A Critical Mismatch

The issue is not a problem with the child, but a mismatch between the child and the school environment.

Neurodivergent Students in School Difficulty Cohorts

Research shows high correlation, DATA BEING UPDATED [5].

Common Environmental Triggers:

🔊 Sensory Overload

Loud bells, bright lights, crowded hallways, uncomfortable uniforms.

🤯 Social Exhaustion

The constant effort of navigating unwritten social rules and peer interactions.

❓ Unpredictability & Demand

Changes in routine, academic pressure, and even simple instructions can trigger intense anxiety [6].

A Framework for Intervention (MTSS)

Effective support is tiered, moving from universal prevention to intensive, individualized care [7].

TIER 3: INTENSIVE (~5%)

Intensive case management, wrap-around services for student and family, Functional Behavior Assessment (FBA).

TIER 2: TARGETED (~15%)

Personalized outreach, staff mentors (Check-In/Check-Out), small group interventions for social skills or anxiety.

TIER 1: UNIVERSAL (All Students)

Positive school climate, school-wide social-emotional learning (SEL), strong family-school partnerships, attendance awareness.

Key Clinical Takeaways

Core principles to guide assessment and treatment planning.

1. Prioritize Safety Over Attendance

The primary goal is not a rapid return to school, but restoring the child's physiological sense of safety. Interventions like graded exposure may be re-traumatizing if a foundation of safety and trust is not first established [8].

2. Look for Mismatch, Not Pathology

Assume the behavior is a rational response to an overwhelming environment. The clinical task is to identify the environmental triggers (sensory, social, academic) and advocate for accommodations, rather than focusing solely on the child's internal state [9].

3. Empower the Parents

Parents are often exhausted, blamed, and navigating a confusing system. Validating their experience and equipping them with skills (e.g., via models like SPACE) to reduce accommodation while building connection is a powerful lever for change [10].

A Practical Lens: Dr. Mona Delahooke's 'Bottom-Up' Approach [8]

This framework, based on the work of Dr. Mona Delahooke, helps reorient the clinical focus from managing behaviors to understanding the child's physiological state.

Instead of asking...

"How do we get the child to comply?"
"What are the consequences for this behavior?"

Ask...

"What is the state of this child's nervous system?"
"What cues of safety does this child need right now?"

'Track Better': Observing the Nervous System

😊

Safe / Social

Relaxed body, melodic voice, engaged eyes, playful.

😡

Mobilized / Stressed

Tense muscles, loud/fast voice, wide eyes, agitated.

🧊

Collapsed / Shutdown

Limp/heavy body, flat/no voice, vacant eyes, still/slow.

Reference List

Kearney, C. A. (2021). 'Helping children and adolescents with school refusal: A clinician’s guide'. Oxford University Press.
Cook, L. (2024, May 15). The 'school can't' crisis: Why are more than 40% of Australian kids missing so much school?. 'The Guardian'.
Elliott, J. G., & Place, M. (2019). 'Practitioner’s guide to emotionally based school avoidance'. Jessica Kingsley Publishers.
Morgan, G. (2022). 'School distress: A better way to think about school refusal'. Emerging Minds.
Totsika, V., Hastings, R. P., Dutton, Y., Worsley, A., & Melvin, G. (2020). Types and correlates of school attendance problems in a community sample of children with intellectual disabilities. 'Journal of intellectual disability research, 64'(9), 688-698.
McKay-Brown, L., Ryder, S., & Wallace, K. (2023). Supporting Autistic Students Experiencing School Refusal. In 'Pedagogical Approaches to Support Diverse Learning Needs in the Modern Classroom' (pp. 215-236). IGI Global.
Gubbels, J., van der Put, C. E., & Assink, M. (2019). Risk factors for school absenteeism and dropout: A meta-analytic review. 'Journal of youth and adolescence, 48'(9), 1637-1667.
Delahooke, M. (2022). 'Brain-body parenting: How to stop managing behavior and start raising joyful, resilient kids'. HarperCollins.
Pellicano, E., & den Houting, J. (2022). Annual Research Review: Shifting from ‘normal’ science to neurodiversity science for a more inclusive and equitable future. 'Journal of Child Psychology and Psychiatry, 63'(4), 381-396.
Lebowitz, E. R. (2021). 'Breaking free of child anxiety and OCD: A scientifically proven program for parents'. Oxford University Press.