School Absenteeism and the COVID-19 Pandemic: The Role of Pediatricians

School closures during the COVID-19 pandemic signified a turn in education. During the 2020-2021 school year, school attendance rates dropped significantly compared with previous years, and absenteeism was more severe in school districts that closed for in-person instruction than those districts that remained open during the pandemic. ¹ Although school districts across the United States have now reopened for in-person learning, school attendance has continued to remain below prepandemic levels, most notably among low-income and black and Hispanic students. ²

This school attendance decrease poses a risk for negative outcomes in children. ³ School attendance is an even better predictor of school performance than test scores. ⁴ Prior research suggests that chronic absenteeism, or missing at least 15 days of school in a year, impacts academic outcomes; for example, absenteeism in first grade affects reading level in the third grade. Furthermore, the incidence of chronic absenteeism in 1 year between grades 8 and 12 is associated with a 7-fold increase in school dropout rates. ⁵ As a driver of academic outcomes, school absenteeism also has long-term implications for health and social functioning. Extensive research has shown an unequivocal association between low educational achievement and poor social and health outcomes, ⁶ including unemployment and low-paying jobs, unhealthy habits such as smoking and lack of exercise, and increased mortality and lower life expectancy.^6-8

The importance of school attendance was understood early on in the history of US education when compulsory attendance laws were introduced by Puritan leaders as early as 1642. By 1890, the majority of US states had passed compulsory education laws. These laws were and continue to be mostly nonenforceable and have had only modest success in increasing attendance.^9,10 Strategies to encourage school attendance, therefore, largely take place outside of the legal system and generally rely on multidisciplinary support from physicians and other professionals in a child’s life (eg, teachers, therapists). ¹¹ In the context of concerns for the 6.5 million children with chronic absenteeism, a prepandemic policy statement called pediatricians to promote regular school attendance. ³ Recommendations included multisector interventions involving school nurses, school-based health centers, mental health services, and families. The need to propel this message is critical at a time of decreased school attendance rates following the COVID-19 pandemic.

Risk factors for chronic absenteeism are multilayered and include individual factors, such temperament, medical and psychiatric comorbidities, low self-esteem, and a heightened sensitivity to school failures; peer-related factors, such as difficulties with peer relationships and bullying; school-related factors, such as the school climate, school connectedness, or the child’s perception of safety and feelings of being valued at school; and family-related factors, such as poverty, homelessness, being in a single-parent household, parental history of psychiatric illness, low parent involvement or high conflict, and family enmeshment. ³ Finally, structural issues, such as limited transportation and neighborhood violence, can be obstacles to school attendance and are particularly prevalent in disadvantaged communities. During the COVID-19 pandemic, typical structural contributors may have been amplified. These structural barriers to school attendance during the pandemic may have included having to supervise younger siblings, lacking access to the internet or a computer to attend virtual class, and lacking parental supervision of daytime activities when parents had jobs that required in-person attendance, among others. In addition, social media use among children and adolescents, known to be associated with both school absenteeism ¹² and the underlying contributors to absenteeism (eg, low self-esteem, social anxiety, sleep), ¹³ rose significantly during the pandemic. ¹⁴

School absenteeism is an umbrella term that includes 2 major agreed-upon types of school absences. ¹⁵ The first type is Anxious School Refusal (ASR), also called “School Phobia” or school avoidance. Anxious School Refusal, identified in the 1930s and 1940s, is characterized by a persistent reluctance to attend school that stems primarily from anxiety (eg, fear of separation from caregivers, anxiety related to school performance). ¹⁶ The second type of school absenteeism, truancy, describes students who are frequently absent from school in the context of broader psychopathology such as symptoms consistent with conduct disorder. A North Carolina longitudinal study ¹⁵ described a third mixed group presenting with both anxiety and truancy in the context of high levels of personal and parental psychopathology. Notably, all groups of school-absent students demonstrate higher rates of psychiatric disorders compared with children who attend school regularly. The presentation of school avoidance varies by developmental stage, and absenteeism may worsen after lengthy school breaks such as summer vacations, holiday breaks, long weekends, and brief illnesses, as well as following stressful occurrences, such as the death of a relative or a move or change of school.^16,17

Regardless of the type of school absenteeism, there are steps that can be taken to ensure a child gets back into a routine of regular school attendance. Kearney and Graczyk ¹⁸ proposed a 3-tiered response-to-intervention model to address school avoidance. Universal interventions geared toward all students focus on school climate, safety and health-based strategies, parent involvement, culturally responsive teaching, summer bridge and school readiness programs, and review of school attendance policies. Targeted Interventions for those students with more significant school attendance problems may require psychological treatment, with interventions that target the behavioral processes underlying absenteeism for both anxiety and non-anxiety-based absenteeism. The treatment approach for anxiety-driven school avoidance involves school exposure. This exposure typically includes immediate or gradual steps toward engaging in feared situations, with the goal of ending the cycle of negative reinforcement and showing the child that they can successfully face their school-related fears. Treatment for inadvertent reinforcement of negative behaviors by the child’s environment includes behavioral treatments such as parent management training. These interventions involve teaching behavioral principles to the parents, collaboratively applying those behavioral principles to the child, and redistributing reinforcement in the child’s life such that brave behavior is rewarded and negative behavior is decreased, usually through planned ignoring. Parent and school partnerships can be beneficial and may involve escorting the child to school, providing positive reinforcement for attendance, decreasing positive reinforcement for staying at home, and decreasing parent’s anxiety. The third tier, Intensive Interventions, may involve an expansion of targeted interventions for the most severe cases of school absenteeism, but may also involve alternative educational programs and legal strategies.

Early and multisystemic interventions to address school avoidance should involve parents, school staff, and other individuals in the child’s care. The primary goal of treatment is always an early return to school. Therefore, it is important for pediatricians and other clinicians to avoid enabling further school avoidance (eg, by writing letters excusing school absences) unless there is a medical condition that requires absences. Distinguishing somatic symptoms due to psychological distress is essential, as mental health conditions such as anxiety or depression are not an indication for excused school absences. The focus of treatment should instead address the underlying problem.^11,19

In the clinical setting, the first step to address school absenteeism involves doing a thorough assessment. This assessment should include a focused clinical interview to establish the nature of school refusal that should include the child, parent, and teacher reports; a physical examination to rule out organic cause of physical symptoms; and structured behavioral ratings and observations to assess behavioral and mental health comorbidities. It is particularly important to assess and understand the function behind school refusal. The School Refusal Assessment Scale, Revised Edition (SRAS-R) ²⁰ is a 24-item questionnaire that measures 4 main factors believed to drive school refusal. The SRAS-R is free to use and widely available online. These identified factors (or functions) can be used by clinicians to guide the intervention approach (see Table 1) and include avoidance of school-related situations that cause distress in the child; escape from uncomfortable social or other situations, such as tests; receiving attention by others outside of the school; and pursuing rewards outside of the school. For example, a child who avoids school because they are trying to escape a difficult social situation may suffer from social anxiety and may benefit from role-playing or social skills groups, whereas a child who stays home to receive attention from others outside of school may suffer from separation anxiety or oppositional defiant disorders and may benefit from parent training or contingency management.

Table 1.

Guidance on School Refusal Assessment, Revised Edition Functions and Recommended Interventions in the Pediatric Clinic.

Function	Intervention
AVOIDANCE of school related stimuli that provoke negative affectivity/anxiety	Exposure to school (immediate or gradual) Systematic desensitization Relaxation exercises (eg, breathing exercises, progressive muscle relaxation) Self-reinforcement, self-talk, self-esteem building
ESCAPE from aversive social interactions at school	Modeling and role-playing of feared situations Cognitive restructuring of negative self-talk Social skills training Coping strategies training
ATTENTION from parent, caregiver, or significant other	Clear parental message Parent training in contingency management (eg, consequences for compliance/noncompliance) and maintaining consistent expectations Establish and maintain morning and evening routines
REINFORCERS outside the school	Family therapy Increase rewards for attending and decrease rewards for missing school (contingency management) Curtail social and other activities for nonattendance

Source. Modified from Kearney and Graczyk’s ¹⁸ work

Overall, important ingredients of school refusal interventions include cognitive-behavioral therapy (CBT) to challenge any cognitive distortions surrounding school attendance, systemic desensitization such that the student is progressively exposed to the feared school-related situations, and relaxation techniques so that the student can manage any increased anxiety when attending school. Most students also benefit from an individualized school re-entry plan to include clear expectations, routine, structure, and sleep so that school attendance becomes a habit. For students who struggle with the social aspects of school, peer buddy systems that can help the student navigate the school with social support and social skills training can empower students to effectively manage social situations.

While pediatricians may not have the ability to conduct complex behavioral interventions due to time constraints, they can provide psychoeducation about the consequences of poor school attendance, screen children at risk, and collaborate with mental health providers and schools. Pediatricians may also need to involve Child and Family services in cases of severe absenteeism. An understanding of the functions of school avoidance and the ways in which these guide interventions can also support pediatricians in referring patients to the most appropriate services. Mental health partnerships can aid with behavioral interventions that can be provided by behavioralists, clinical social workers, and occupational therapists and psychologists, such as exposure, systematic desensitization, relaxation training, contingency management, CBT, and social skills training. In addition, pediatricians can emphasize the importance of routine and structure, sleep hygiene, healthy use of technology and social media usage, and peer buddy support in all well-child visits. Regarding pharmacological interventions for school avoidance, few double-blind, placebo-controlled studies exist, with inconclusive data to guide best practices. While not indicated as a sole intervention, selective-reuptake receptor inhibitors can be used for comorbid anxiety or depression, and benzodiazepines can be used in the context of acute school exposure during therapy, although not indicated as a treatment for chronic school absences.^11,19

In addition to collaborative care models with pediatricians, mental health services collocated in schools may be able to serve as a bridge between the home and the school when it comes to preventing and treating school avoidance for anxious students or school refusal for children and adolescents with truancy. School-based mental health services are programs and interventions designed to address emotional, behavioral, or social functioning issues that are applied in school settings. While the models vary, they consist of schools receiving mental health support from professionals who can consult, assess, and treat students in the school setting.^21-25 These services facilitate access and are cost-efficient, allowing youth in need to circumvent problems such as mental health stigma or lack of transportation. Interventions such as CBT techniques, social skills training, and teacher consultation models have all proven to be effective school-based mental health interventions for children’s and adolescents’ mental health and could all have a role in helping children return to school. Effective strategies for prevention may involve teachers and other school staff, such as using curriculums that focus on positive behavioral supports for mental health, starting mental health education at an early age, improving school climate, and involving the community in coordination of services and parent education, communication, and coordination.

In sum, school attendance is a major modifiable risk factor that contributes to health and social outcomes across a person’s lifetime. Prolonged school closures and educational disruption during the COVID-19 pandemic may have exacerbated an already existing school attendance problem. It is imperative that all actors in the life of children ensure the conditions are met for regular school attendance, with early and evidence-based interventions provided to children who require additional support. Because of the unique family-based longitudinal follow-up that pediatricians provide for children, pediatricians have the potential to play a key role in promoting school attendance. Models of collaboration with mental health services located in the pediatrician’s clinic or in the school setting may help students return and stay engaged in school.

Author Contributions

CV: Conceptualized the study; drafted the initial manuscript; and reviewed and revised the manuscript. LH: Conceptualized the study; critically reviewed the manuscript for important intellectual content. EB: Conceptualized the study; critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.