School Absenteeism in Children and Adolescents


Am Fam Physician. 2018 Dec 15;98(12):738-744.

  Patient information: See related handout on school absences, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Frequent school absenteeism has immediate and long-term negative effects on academic performance, social functioning, high school and college graduation rates, adult income, health, and life expectancy. Previous research focused on distinguishing between truancy and anxiety-driven school refusal, but current policy has shifted to reducing absenteeism for any reason. Chronic absenteeism appears to be driven by overlapping medical, individual, family, and social factors, including chronic illness, mental health conditions, bullying, perceived lack of safety, health problems or needs of other family members, inconsistent parenting, poor school climate, economic disadvantage, and unreliable transportation. Family physicians are well positioned to identify patients with frequent absences, intervene early, and tailor treatment plans to the patient’s medical and social needs. Informing parents of the link between school attendance and achievement can be effective in reducing absences. If absenteeism is caused by chronic illness, management should include clear expectations about school attendance and care coordination with school personnel. Mental health conditions that interfere with school attendance can often be treated with cognitive behavior therapy and/or pharmacotherapy. When assessing a child with frequent absences, physicians should inquire about bullying, even if the patient is not known to identify with a vulnerable group. Families and schools are key collaborators in interventions via parent education, parental mental health treatment, and school-based intervention programs.

Frequent school absences are associated with lifelong negative academic, social, and health sequelae,1,2 yet often go unnoticed and unaddressed by schools and government organizations.3 School absenteeism has been called a public health issue and a hidden educational crisis.4,5 It is a complex and varied phenomenon with often interrelated causes. Interventions to reduce absenteeism previously focused on distinguishing truancy from excused absences because of anxiety-driven school refusal. However, recent evidence has shown that missing school is often detrimental even with the permission of parents or physicians,3 and the emphasis has shifted to reducing absenteeism for any reason.6

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Clinical recommendationEvidence ratingReferences

Parents should be informed about the connection between regular school attendance in early grades and academic success.


42, 43

Physicians can use well-child visits to prepare families for kindergarten (e.g., establishing bedtime and morning routines) and to recommend preschool to families with risk factors for absenteeism.


23, 45, 46

To address absenteeism in children with chronic illness, physicians should set expectations for regular school attendance; make a written action plan including an individualized emergency protocol, medication list, monitoring instructions, environmental triggers, and emergency contact information; and offer ongoing consultation.


56, 57

For children with serious illness who need to miss school for treatment, physicians should discuss the likely timeframe for returning, then communicate with school personnel about the patient’s needs once he or she has returned to school.



For children with academic and behavior problems, physicians should ensure that parents are aware of available school-based educational support services, and consider referral for mentoring and cognitive support.



For children with depression or anxiety who miss school:

Physicians should recommend cognitive behavior therapy or other psychotherapy focused on a graduated return to school.



Physicians should consider prescribing a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor.



Physicians should recommend family involvement in therapy.


50, 66

Physicians should connect students with school-based mental health resources when available.



Physicians should screen and treat mothers of school-aged children for depression.


31, 51, 67

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to


Clinical recommendationEvidence ratingReferences

Parents should be informed about the connection between regular school attendance in early grades and academic success.


42, 43

Physicians can use well-child visits to prepare families for kindergarten (e.g., establishing bedtime and morning routines) and to recommend preschool to families with risk factors for absenteeism.


23, 45, 46

To address absenteeism in children with chronic illness, physicians should set expectations for regular

The Authors

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CLAUDIA W. ALLEN, PhD, JD, is an associate professor and director of behavioral science in the Department of Family Medicine at the University of Virginia School of Medicine, Charlottesville....

SHARON DIAMOND-MYRSTEN, MD, MS, is an assistant professor in the Department of Family Medicine at the University of Virginia School of Medicine.

LISA K. ROLLINS, PhD, is an associate professor, director of scholarship, and director of the faculty development fellowship in the Department of Family Medicine at the University of Virginia School of Medicine.

Address correspondence to Claudia W. Allen, PhD, JD, University of Virginia Health System, UVA Health Sciences Center, P.O. Box 800729, Charlottesville, VA 22908-0729 (e-mail: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

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