Emotionally Based School Avoidance

Emotionally Based School Avoidance (EBSA) is a broad umbrella term used to describe children and young people who have difficulty in attending school due to emotional needs. This can include decreases in attendance, patterns of non-attendance (for example Mondays), and prolonged absences from school. The onset of EBSA may be sudden or gradual. The literature suggests that there tends to be peaks in EBSA corresponding to transition between school phases and year groups (King & Bernstein, 2001). We recognise that all behaviours are a communication of an emotional need that is either unmet, or being met elsewhere. It might not always look like an emotional need but our knowledge about trauma helps us see beyond what children and young people say and the externalising behaviours they may present with. It is important to remember survival mode and how differently the fight, flight, freeze response can present.

Although the literature in this area often cites the phrase ‘School Refuser’, this terminology could be considered misleading as the term ‘refuser’ implies that the young person has control over the school non-attendance. Language is very powerful. The first intervention is to change the language used around this by professionals and families. By changing the language used, the way we choose to intervene will change.

Anxiety has been identified as a key feature of EBSA. Although a certain level of anxiety is considered a normal and natural part of growing up and we can teach coping mechanisms to function with anxiety in everyday life, sometimes this escalates.

When the anxiety is linked to school avoidance, the young person may experience anxious and fearful thoughts around attending and coping with school. These feelings may also be accompanied by physiological symptoms of anxiety such as nausea, vomiting, shaking, sweating etc. and may start the night before, or even a few days before school. In order to avoid these overwhelming emotions and the fear associated with school attendance, students might use the fight, flight, freeze survival response. These behaviours, and the avoidance of school, may then contribute to the maintenance of EBSA over time.

Possible indicators of EBSA

Although there is a higher prevalence of EBSA among secondary students, signs of school avoidance may appear during primary school. The longer the problem goes unaddressed, the bigger it becomes and the greater the intervention needed. It is crucial to identify this early (i.e. when attendance drops to 90%) and put support in place to ensure a rapid return to school.

Possible indicators include: 

• Difficulty attending school with periods of prolonged absence
• Child reluctant to leave home and stays away from school with the knowledge of the parent/carer
• For younger children, reluctance to leave parents or get out of the car
• Regular absence
• Frequent absences for minor illnesses
• Patterns in absences, for example, particular days and/or subjects, after weekends and holidays
• Reluctance to attend school trips
• The young person expresses a desire to attend classes but is unable to do so
• Anxiety on separation and dependence on family members e.g. worry expressed about the safety of those at home
• Evidence of under-achievement in learning
• Social isolation and avoidance of class mates or peer group
• Challenging behaviours, particularly in relation to specific situations at school
• Severe emotional upset with excessive fearfulness, outbursts of temper and complaints of feeling ill on school days
• Depression, low self-esteem and low confidence
• Confusion or extreme absent mindedness due to lack of concentration
• Physical changes i.e. sweating, sickness, aching limbs, headaches, panic attacks, abdominal pain, rapid weight loss or gain
• Withdrawal in class for example head on desk, hood up, avoiding work or interactions

Risk/resilience factors

Just as with general mental health, there have been factors identified that place children at greater risk of EBSA. It is usually a combination of factors interacting with a change in circumstances that leads to what we see as EBSA. The predisposing factors may be present in the nature of the school, the child’s family or the child themselves.

‘Push and Pull’ factors

The literature indicates that Emotionally Based School Avoidance is most likely to occur when the risks are greater than resilience, when stress and anxiety exceeds support, and when the factors that promote school avoidance overwhelm the factors that encourage school attendance. By mapping out what is going on for a young person, you can identify where there are imbalances which would tell you how to intervene to support a young person.

Perspectives and blame

It is often tempting to try to locate a simple reason and simple solution for behaviour. However as identified earlier it is often an interaction of a number of factors and trying to find simple causation often encourages blaming. Individuals can then become anxious and defensive. Parents may feel blamed for the absences, feel that their parenting skills are being criticised and they may be fearful that they will get into trouble or even prosecuted for nonattendance. Children may feel guilty or scared that they will be forced to attend school.

Each person may have a different perspective on EBSA and have a different story to tell. It is essential that different people’s views are respected and differences in views are acknowledged. When there is a difference of views it is often more helpful to focus on how the behaviour is occurring rather than why.

Attachment strategies

• Support development of a secure attachment at home so that the young person feels like they are able to separate. This may involve creating special time to be spent together which will vary depending on age, or more specialist intervention, such as Video Interactive Guidance (VIG)
• Consider using transitional objects such as teddies, hair ties, photos, keyring that the child can take from home into school
• Give the child some protected quality time with you at home (‘special time’)

Managing feelings

• Acknowledge that anxiety is ok but don’t over re-assure or dismiss the feeling. Accept the child’s emotional experience of school, allow them to feel heard and normalise their experience.
• Encourage and positively affirm the child when they go to school (e.g. ‘I’m really happy for you’)
• Try to present a balanced view when talking about school and try to avoid negative narratives about school (‘I was never good at Maths either’)
• Encourage the child to engage in mindfulness or other activities that may make them feel relaxed (e.g. mindful colouring)

Routine and predictability

• Make the school day as predictable as possible by creating a visual planner for the week and checklists for school equipment. Encourage the child to tick days spent at school off on a calendar as they achieve them
• Ensure a clear routine is in place. This may include use of visuals/weekly planner/organisation, etc. It is important to try and capitalise on a sense of momentum. It may be easier to keep going through the week and routine helps with this

Attachment strategies

• Create a sense of belonging in school by greeting the child when entering school/class and giving them a role and responsibility
• When the child is not at school, continue to communicate with them via email, notes, video calls etc
• Start and end the school day with protected quality time with a safe, consistent adult for 15 minutes
• Ensure there is a clear transition between parent/s and a trusted staff member at the start of each day
• Ensure the child sees positive interactions between home and school
• Consider using transitional objects such as teddies, hair ties, photos, keyring that the child can take from home into school. Allow them to text or phone home during the school day if needed

Routine and predictability

• Ensure that the school day is predictable by creating a consistent routine that it outlined on a visual schedule.
• Try to keep elements of the school day the same (e.g. entering school via the same route each day, having the same settling activity at the start of the day) 
• Consider the safe spaces that pupils can go to, such as a pastoral zone or library, as these may be less stigmatising for some pupils than the learning support area
• Encourage and positively affirm the child when they go to school (e.g. ‘I’m really happy that you’ve come into school today’)
• Encourage the child to engage in mindfulness or other activities that may make them feel relaxed (e.g. mindful colouring)

Additional interventions

• Additional strategies may include: Anti-bullying programmes , buddying pupils, mentoring and teaching coping strategies
• Support the child with peer interactions (e.g. circle of friends, social skills groups)

Making change manageable

Re-exposure to school should happen gradually, using an avoidance hierarchy created with the young person from least feared school situation to most feared. To create an avoidance hierarchy, the young person can be asked to name situations (or shown cards representing possible fears) and rank them in terms of how they feel about that situation or object from ‘least worried about’ to ‘most worried about’. When thinking about next steps it is important to start with the item that causes the least amount of anxiety, helping them think about how they will cope with this situation and what support they will need. When they have overcome this fear and consolidated this a number of times, they can begin to work his or her way up the hierarchy.

When supporting young people to manage negative feelings or high levels of stress in certain experiences (e.g. fear of the toilets; the noise in the playground; lots of people moving all together in the corridors between classes, tests/ exams), interventions should include learning about anxiety and how it affects our thinking, feelings and behaviours. The child should be taught anxiety management techniques such as relaxation training and deep breathing.

Schools should take a multi-agency 'team around the child' approach to discuss cases where there is there is school avoidance, involving their link Educational Psychologist, Early Help, health practitioners, Mental Health Support Teams, CAMHS and any other relevent service as appropriate.

The approaches of multi-agency practitioners with regards to EBSA are aligned following the Multi-agency School Avoidance Groups that were convened to discuss this topic.

Links to teams who can support you with EBSA are provided below:

• Educational Psychology Consultation Service
• Early Help
• Mental Health Support Teams
• CAMHS
• School Health Service
• Bi-borough Inclusion Service
• Virtual School for Looked After Children
• Kooth

• Huge Bag of Worries by Virginia Ironside
• Worry Box: managing anxiety in young children by Hannah Mortimer
• When my worries get too big! A relaxation book for children who live with anxiety, 2nd Edition by Kari Dunn-Buron
• A Volcano in My Tummy by Elaine Whitehouse and Warwick Pudney.
• Starving the Anxiety Gremlin: A Cognitive Behavioural Therapy Workbook on Anxiety Management for Young People by Kate Collins-Donnelly
• Sitting Still Like a Frog: Mindfulness Exercises for Kids (and Their Parents) by Eline Snel
• Dealing with Feelings by Tina Rae
• My Book of Feelings by Tracey Ross
• Get Out of Your Mind and Into Your Life for Teens by Joseph V. Ciarrochi, Louise Hayes and Ann Bailey.
• Anxiety by Paul Stallard -Examples of activities http://tandfbis.s3.amazonaws.com/rt
• media/pp/resources/CBTCHILD/worksheets.pdf
• Supporting Children and Young People with Anxiety: A Practical Guide by Elizabeth Herrick and Barbara Redman-White
• Promoting Emotional Resilience- Toolkit http://hbtg.org.uk/wpcontent/uploads/2015/06/KAN-Emotional-resilience-toolkit.pdf