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

 Enlarge     Print


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

show all author info

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

1. Gottfried MA. Chronic absenteeism and its effects on students’ academic and socioemotional outcomes. J Educ Students Placed Risk. 2014;19(2):53–75....

2. Oregon Education Investment Board. Oregon learns: the strategy to get to 40/40/20. August 2011. Accessed June 20, 2018.

3. Bruner C, Discher A, Chang H. Chronic elementary absenteeism: a problem hidden in plain sight. Attendance Works, Child & Family Policy Center. November 2011. Accessed June 20, 2018.

4. Henderson T, Hill C, Norton K. The connection between missing school and health: a review of chronic absenteeism and student health in Oregon. Upstream Public Health. October 2014. Accessed June 20, 2018.

5. U.S. Department of Education. Chronic absenteeism in the nation's schools: an unprecedented look at a hidden educational crisis. June 2016. Accessed June 20, 2018.

6. Stevens AC, Gervey CK. Chronic absenteeism report. Portland State University Center to Advance Racial Equity. May 2016. Accessed June 20, 2018.

7. Attendance Works. Preventing missed opportunity: taking collective action to confront chronic absence. September 2016. Accessed June 20, 2018.

8. Chang HN, Romero M. Present, engaged, and accounted for: the critical importance of addressing chronic absence in the early grades. National Center for Children in Poverty. September 2008. Accessed June 20, 2018.

9. Education Commission of the States. Chronic early absence. February 2010. Accessed June 20, 2018.

10. Miller LC, Johnson A. Chronic absenteeism in Virginia and the challenged school divisions: a descriptive analysis of patterns and correlates. University of Virginia EdPolicy Works. September 2016. Accessed June 20, 2018.

11. Stearns E, Glennie EJ. When and why dropouts leave high school. Youth Society. 2006;38(1):29–57.

12. U.S. Department of Education. 2013–2014 Civil rights data collection: a first look. June 7, 2016. Accessed June 20, 2018.

13. Chang HN, Jordan PW. Tackling chronic absence starting in the early grades: what cities can do to ensure every child has a fighting chance to succeed. National Civic Review. 2011. Accessed June 20, 2018.

14. Eaton DK, Brener N, Kann LK. Associations of health risk behaviors with school absenteeism. Does having permission for the absence make a difference?. J Sch Health. 2008;78(4):223–229.

15. Balfanz R, Durham R, Plank S. Lost days: patterns and levels of chronic absenteeism among Baltimore City public school students 1999–00 to 2005–06. 2008. Accessed June 20, 2018.

16. Hickman GP, Bartholomew M, Mathwig J, Heinrich RS. Differential developmental pathways of high school dropouts and graduates. J Educ Res. 2008;102(1):3–14.

17. Reynolds AJ, Temple JA, Robertson DL, Mann EA. Age 21 cost-benefit analysis of the Title I Chicago child-parent centers. Educ Eval Policy Anal. 2002;24(4):267–303.

18. Ginsburg A, Chang H, Jordan P. Absences add up: how school attendance influences student success. Attendance Works. August 2014. Accessed June 20, 2018.

19. Nauer K, White A, Yerneni R. Strengthening schools by strengthening families: community strategies to reverse chronic absenteeism in the early grades and improve supports for children and families. Center for New York City Affairs, The New School for Management and Urban Policy. October 2008. Accessed June 20 2018.

20. Balfanz R, Byrnes V. The importance of being in school: a report on absenteeism in the nation's public schools. Johns Hopkins University Center for Social Organization of Schools. May 2012. Accessed June 20, 2018.

21. Kerr J, Price M, Kotch J, Willis S, Fisher M, Silva S. Does contact by a family nurse practitioner decrease early school absence? J Sch Nurs. 2012;28(1):38–46.

22. Henry KL. Who's skipping school: characteristics of truants in 8th and 10th grade. J Sch Health. 2007;77(1):29–35.

23. Gottfried MA. Can center-based childcare reduce the odds of early chronic absenteeism? Early Child Res Q. 2015;32:160–173.

24. Gilliland FD, Berhane K, Islam T, et al. Environmental tobacco smoke and absenteeism related to respiratory illness in schoolchildren. Am J Epidemiol. 2003;157(10):861–869.

25. Ramirez M, Wu Y, Kataoka S, et al. Youth violence across multiple dimensions: a study of violence, absenteeism, and suspensions among middle school children. J Pediatr. 2012;161(3):542–546.e2.

26. Hella B, Bernstein GA. Panic disorder and school refusal. Child Adolesc Psychiatr Clin N Am. 2012;21(3):593–606.

27. Kearney CA. School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev. 2008;28(3):451–471.

28. Hunt MK, Hopko DR. Predicting high school truancy among students in the Appalachian south. J Prim Prev. 2009;30(5):549–567.

29. Romero M, Lee YS. A national portrait of chronic absenteeism in the early grades. National Center for Children in Poverty. October 2007. Accessed June 20, 2018.

30. Hochadel J, Frölich J, Wiater A, Lehmkuhl G, Fricke-Oerkermann L. Prevalence of sleep problems and relationship between sleep problems and school refusal behavior in school-aged children in children's and parents’ ratings. Psychopathology. 2014;47(2):119–126.

31. Claessens A, Engel M, Curran FC. The effects of maternal depression on child outcomes during the first years of formal schooling. Early Child Res Q. 2015;32:80–93.

32. Gase LN, Kuo T, Coller K, Guerrero LR, Wong MD. Assessing the connection between health and education: identifying potential leverage points for public health to improve school attendance. Am J Public Health. 2014;104(9):e47–e54.

33. Nichols EB, Loper AB, Meyer JP. Promoting educational resiliency in youth with incarcerated parents: the impact of parental incarceration, school characteristics, and connectedness on school outcomes. J Youth Adolesc. 2016;45(6):1090–1109.

34. Ingul JM, Klöckner CA, Silverman WK, Nordahl HM. Adolescent school absenteeism: modelling social and individual risk factors. Child Adolesc Ment Health. 2012;17(2):93–100.

35. Birkett M, Russell ST, Corliss HL. Sexual-orientation disparities in school: the mediational role of indicators of victimization in achievement and truancy because of feeling unsafe. Am J Public Health. 2014;104(6):1124–1128.

36. Allen G. The impact of elementary school nurses on student attendance. J Sch Nurs. 2003;19(4):225–231.

37. MacNaughton P, Eitland E, Kloog I, Schwartz J, Allen J. Impact of particulate matter exposure and surrounding “greenness” on chronic absenteeism in Massachusetts public schools. Int J Environ Res Public Health. 2017;14(2):207.

38. Duncan GJ, Dowsett CJ, Claessens A, et al. School readiness and later achievement [published correction appears in Dev Psychol. 2008;44(1):232]. Dev Psychol. 2007;43(6):1428–1446.

39. Di Bartolo CA, Braun MK. School refusal. In: Pediatrician's Guide to Discussing Research with Patients. New York, NY: Springer; 2017:225–238.

40. Kearney CA. Forms and functions of school refusal behavior in youth: an empirical analysis of absenteeism severity. J Child Psychol Psychiatry. 2007;48(1):53–61.

41. Haight C, Kearney CA, Hendron M, Schafer R. Confirmatory analyses of the School Refusal Assessment Scale-Revised: replication and extension to a truancy sample. J Psychopathol Behav Assess. 2011;33(2):196–204.

42. Robinson CD, Lee MG, Dearing E, Rogers T. Reducing student absenteeism in the early grades by targeting parental beliefs: faculty research working paper series. Harvard University John F. Kennedy School of Government. March 2017. Accessed June 20, 2018.

43. Rogers T, Duncan T, Wolford T, Ternovski J, Subramanyam S, Reitano A. A randomized experiment using absenteeism information to “nudge” attendance. U.S. Department of Education; Institute of Education Sciences. February 2017. Accessed June 20, 2018.

44. Korematsu S, Takano T, Izumi T. Pre-school development and behavior screening with a consecutive support programs for 5-year-olds reduces the rate of school refusal. Brain Dev. 2016;38(4):373–376.

45. Tseng AG, Biagioli FE. Counseling on early childhood concerns: sleep issues, thumb sucking, picky eating, and school readiness. Am Fam Physician. 2009;80(2):139–142.

46. Council on Early Childhood; Council on School Health. The pediatrician's role in optimizing school readiness. Pediatrics. 2016;138(3):e20162293.

47. James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2015;(2):CD004690.

48. Guryan J, Christenson S, Claessens A, et al. The effect of mentoring on school attendance and academic outcomes: a randomized evaluation of the Check & Connect program (WP-16–18). Northwestern University Institute for Policy Research. February 9, 2017. Accessed June 20, 2018.

49. Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2009;(3):CD005170.

50. Eisen AR, Raleigh H, Neuhoff CC. The unique impact of parent training for separation anxiety disorder in children. Behav Ther. 2008;39(2):195–206.

51. Guevara JP, Mandell D, Danagoulian S, Reyner J, Pati S. Parental depressive symptoms and children's school attendance and emergency department use: a nationally representative study. Matern Child Health J. 2013;17(6):1130–1137.

52. Gottfried MA. Linking getting to school with going to school. Educ Eval Policy Anal. 2017;39(4):571–592.

53. Ballard KL, Sander MA, Klimes-Dougan B. School-related and social-emotional outcomes of providing mental health services in schools. Community Ment Health J. 2014;50(2):145–149.

54. Kosciw JG, Palmer NA, Kull RM, Greytak EA. The effect of negative school climate on academic outcomes for LGBT youth and the role of in-school supports. J Sch Violence. 2013;12(1):45–63.

55. Jacobsen K, Meeder L, Voskuil VR. Chronic student absenteeism: the critical role of school nurses. NASN Sch Nurse. 2016;31(3):178–185.

56. Glaab LA, Brown R, Daneman D. School attendance in children with type 1 diabetes. Diabet Med. 2005;22(4):421–426.

57. Grant R, Brito A. Chronic illness and school performance: a literature review focusing on asthma and mental health conditions. Children's Health Fund. June 2010. Accessed June 20, 2018.

58. Centers for Disease Control and Prevention. Strategies for addressing asthma within a coordinated school health program. 2006. Accessed June 20, 2018.

59. Wilson KD, Moonie S, Sterling DA, Gillespie KN, Kurz RS. Examining the consulting physician model to enhance the school nurse role for children with asthma. J Sch Health. 2009;79(1):1–7.

60. French AE, Tsangaris E, Barrera M, et al. School attendance in childhood cancer survivors and their siblings. J Pediatr. 2013;162(1):160–165.

61. Sankey A, Hill CM, Brown J, Quinn L, Fletcher A. A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism. Clin Child Psychol Psychiatry. 2006;11(1):126–138.

62. Sexson SB, Madan-Swain A. School reentry for the child with chronic illness. J Learn Disabil. 1993;26(2):115–125, 137.

63. Chu BC, Rizvi SL, Zendegui EA, Bonavitacola L. Dialectical behavior therapy for school refusal: treatment development and incorporation of web-based coaching. Cognit Behav Pract. 2015;22(3):317–330.

64. Afshari A, Neshat-Doost HT, Maracy MR, Ahmady MK, Amiri S. The effective comparison between emotion-focused cognitive behavioral group therapy and cognitive behavioral group therapy in children with separation anxiety disorder. J Res Med Sci. 2014;19(3):221–227.

65. Dube SR, Orpinas P. Understanding excessive school absenteeism as school refusal behavior. Child Schools. 2009;31(2):87–95.

66. Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Evid Based Child Health. 2013;8(2):318–692.

67. Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief maternal depression screening at well-child visits. Pediatrics. 2006;118(1):207–216.

68. Stephens MM, Cook-Fasano HT, Sibbaluca K. Childhood bullying: implications for physicians. Am Fam Physician. 2018;97(3):187–192.

69. Fremont WP. School refusal in children and adolescents. Am Fam Physician. 2003;68(8):1555–1561.



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed


Dec 1, 2019

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article