1. The programme at a glance
Indication. Anxiety-based school refusal in children from around six years old and in adolescents up to eighteen: total or partial absence, repeated lateness, leaving lessons, shortened days, with anxious distress and with no concealment from the parents.
Reference model. Cognitive behavioural therapy for school refusal, in the line of the protocols evaluated since the nineteen-nineties, with graded exposure to the return, work with the parents on the morning and on accommodation, and a written partnership with the school. Accommodation means everything the family has changed in its life to spare the young person their distress, and which maintains the avoidance (session 10, section 27).
Format. Fourteen sessions of 50 minutes. Two sessions a week for the first two weeks, then one a week up to the twelfth, then fortnightly. Four of them are not individual sessions with the young person: two parent sessions, one session with the school, and a final joint session. Two boosters, at one month and at three months.
Mechanism targeted. Not to remove the anxiety before the return to school, but to put the child back there in steps small enough to be held, while treating what keeps them away: the physical sensations of the morning, the thoughts about what awaits them, the social situations of the school, the accumulated backlog, and what those around them do. A step is a precise stage of the return, written down and dated: walking past the school, going in outside lesson hours, attending one chosen lesson, then a half-day. The young person ranks the steps from the easiest to the hardest, and takes them one by one (session 2, section 19).
| Session |
Subject |
Output of the session |
| 1 |
Assess without losing time |
Sorting done, danger ruled out, attendance counted |
| 2 |
The formulation and the return plan |
Diagram drawn, first step dated |
| 3 |
Parent session: the morning |
Morning protocol written |
| 4 |
School session: building the return |
Graded plan signed, named adult identified |
| 5 |
The body: what anxiety does |
Thermometer and two actions |
| 6 |
The first measured step |
First measured step, taken or analysed |
| 7 |
The obstacles of the morning |
Analysis of a failed morning |
| 8 |
Thoughts, and the mid-point review |
One thought examined, review done |
| 9 |
The social situations of school |
Two situations prepared |
| 10 |
Parent session: accommodation |
Two accommodations lifted |
| 11 |
Climbing the steps |
Higher step dated |
| 12 |
Catching up and assessments |
Written catch-up plan |
| 13 |
The full day |
Three whole days held |
| 14 |
Review, relapse, joint session |
Plan written in the young person's own hand |
The "thermometer" of session 5 is a scale from 0 to 10 that the young person draws to rate their fear, and the "two actions" are what they do to stay when it rises (section 22).
What the young person and the parents take away. Seven printable worksheets, listed in section 40 and downloadable from this page: my mornings, my ladder back, my thermometer, my thoughts, my catch-up plan, the parents' corner, my plan for what comes next.
What distinguishes this programme from the other anxiety manuals. Three things. The initial sorting, because four different situations carry the same symptom. The pace, tight at the start, because the length of the absence is the factor most consistently associated with how hard the return will be. And the place of the school, which is not a context but a partner in the treatment, with a session and a written document.
2. Before you begin
The prior question: what is this?
Four decisions come before the first procedure. The first three can be made in the first session; the fourth sometimes needs a specialist opinion.
Is this anxiety-based school refusal? That is the sorting of section 3, and it is the question that governs everything else. An adolescent who skips lessons and hides it from their parents and a child who cries at the school gate do not call for the same response.
Is there ongoing danger? Bullying, cyberbullying, violence. Section 10 says it: no return protocol works on top of it, and looking for it is part of the first session.
For how long? The length of the absence is the variable most closely associated with the prognosis, and the one that sets the pace of the protocol. Three weeks and eight months are not treated at the same tempo. Section 36 covers entrenched refusal.
What lies behind it? Separation anxiety, social anxiety, generalised anxiety, specific phobia, panic disorder, a depressive episode, autism spectrum disorder, a learning disorder. Section 8 gives the differential and section 9 the comorbidities.
What this programme does not treat
It does not treat absenteeism without anxiety. A young person who is not in lessons because they would rather be elsewhere, and who conceals it from their parents, calls for another approach — educational, social, sometimes judicial. Section 3 makes the distinction, and getting it wrong means treating an anxiety that does not exist.
It does not treat withdrawal decided by the parents. When the family itself organises the child's absence from school, the lever is no longer the young person's exposure: it is work with the parents, and sometimes a different setting.
It does not on its own treat severe depression, a psychotic disorder, an eating disorder in the foreground, or a high suicide risk. These are situations where the child psychiatrist's opinion comes first, and where returning to school is not the immediate target.
It does not treat an ongoing situation of abuse or bullying. Protection comes first. See section 10.
How to use it
Read the whole of it before the first session, in particular sections 3, 10, 13 and 33: the sorting, bullying, compulsory schooling, and the morning protocol. These are the four places where mistakes are made, and the first two can have immediate consequences.
Each session is described on the same frame: the aim, the steps, what you say, the common errors, and the criterion for moving on.
A warning specific to this presenting problem. You will be pushed from all sides: by the parents, who cannot take another morning; by the school, which wants a date; sometimes by the young person, who would like to be left alone. The protocol holds precisely because it advances in small dated steps, and not because it extracts a promise of a full return by the second session.
3. Four situations not to be confused
This is the section that decides everything else, and it is the one most often skipped. Four situations present with the same apparent symptom — the child is not in class — and call for neither the same treatment, nor the same interlocutor, nor the same pace (Heyne et al., 2019).
1. Anxiety-based school refusal
What you observe. The young person wants to go to school, or says they would, and cannot. The distress is visible: tears, pleading, physical complaints in the morning, sometimes anger and opposition at the moment of leaving. The parents know where they are: they stay at home, openly.
What goes with it. Physical complaints concentrated on school mornings, fading at the weekend and during the holidays. Anticipatory anxiety on Sunday evening. Correct conduct at school when present. No antisocial behaviour.
What this implies. This is the programme described here.
2. Absenteeism without anxiety
What you observe. The young person is not in lessons and shows no anxious distress. The parents do not always know where they are. The absence is concealed, notes are forged, the days are spent elsewhere.
What goes with it. Often: long-standing disengagement from school, weak results, risk-taking, substance use, a peer group that is not in school either, sometimes offending.
What this implies. A different response: educational, academic, social, sometimes judicial work. Applying an exposure protocol to a young person who is not afraid means treating an anxiety that does not exist — time is lost, and the young person wonders what they are doing there. An important point: the two can coexist, and long-standing absenteeism can come to be compounded by anxiety over time, when the backlog grows too heavy.
3. Withdrawal organised by the parents
What you observe. The absence is decided, or accepted, or maintained by the family. This ranges from the parent who keeps the child at home because they judge them too fragile, to the one who needs their presence at home, to situations where schooling is refused on principle.
What goes with it. Reasons presented as self-evident and rarely discussed: "he is too sensitive", "the level does not suit her", "we are home-schooling him". And often, in the background, parental anxiety, bereavement, illness, isolation.
What this implies. The lever is no longer the young person's exposure. It is work with the parents, and depending on the country, informing or referring to the education authorities. Do not confuse this case with the first: here, a return plan signed by the young person will be worth nothing if nobody at home intends to apply it.
4. Exclusion in practice
What you observe. The young person is not at school because the school, in practice, does not take them: repeated exclusions, no adjustment for a learning disorder or a disability, a placement pending, no available place, bullying left untreated.
What this implies. The work is first with the institution, and sometimes beyond. You do not ask a child to expose themselves to a place that turns them away.
How you decide, in practice
Six questions are asked in the first session, and their answers are gathered from all three sources: the young person, the parents and the school (section 12).
Do the parents know, each day, where their child is during lesson hours? This is the question that separates the first case from the second fastest.
Is there distress in the morning, and does it disappear once the decision to stay is made? Relief after the decision is characteristic of anxious refusal.
Are weekends and holidays different? Symptoms that fade on Saturday point to school anxiety; constant symptoms point elsewhere.
Does the young person say they want to go? It is not proof, but the absence of that wish is telling.
What does the family do in the morning, and for how long has it been like this? A household organised around the absence for six months is a different case from a refusal of a fortnight.
What does the school say? Actual attendance, conduct in class, peer relationships, what has already been tried. See section 12.
Mixed cases, which are common
Many situations are not pure, and there is no point forcing them into a box. An anxious refusal of several months almost always ends up acquiring a share of family organisation around the avoidance — that is not parental withdrawal, it is accommodation, and it is treated in session 10. Long-standing absenteeism ends up producing anxiety about returning once the backlog becomes enormous.
The practical rule: name the anxious part and treat it with this protocol, provided that somebody at home actually supports the return. Without that, you start with the parents.
4. The clinical picture by age
What does not change
Three elements are found at every age. An anticipation that rises the evening before and peaks in the morning. Real physical manifestations — they are not faked, and saying so to the parents is part of the work. And immediate relief as soon as the decision to stay is made, relief which is precisely what maintains the problem.
Before eight
The dominant motive is separation. It is not school that frightens, it is leaving the attachment figure. The child is better as soon as they are in the classroom, and teachers often describe them as fine after twenty minutes.
What you observe. Crying and clinging at the moment of separation, repeated questions about what the parent will do during the day, worries about an accident or an illness befalling the parent, refusal to sleep alone, stomach complaints in the morning.
What misleads. Parents often report that the child "is perfectly fine once they are there", and conclude that there is no problem. That is accurate and settles nothing: what has to be treated is the transition, not the day.
From eight to eleven
The period when the motive diversifies. Separation remains frequent, but there is added fear of a specific event — an assessment, a presentation, swimming, the canteen, the school toilets, the journey — and the first social difficulties.
What you observe. Absences targeted on certain days or certain subjects, repeated trips to the school nurse, calls to the parents during the day, a gradual return to bed once everyone else has left.
What misleads. The selective nature of the absences suggests bad will. On the contrary, it is valuable information: it points to the target.
In adolescence
The dominant motive becomes social and evaluative, and the picture grows heavier.
What you observe. The anxiety concentrates on the gaze of others: entering a classroom late, eating in the refectory, speaking in front of the group, changing rooms, corridors. Panic symptoms are added — heart, breath, dizziness — and often an inversion of the sleep-wake rhythm which makes getting up impossible and becomes a problem in itself.
What worsens with age. The accumulated backlog, which becomes an objective reason not to go back. Isolation, because at this age a few weeks are enough to lose one's place in a group. And the frequency of associated depression, which rises markedly.
What misleads. An adolescent who says "I don't care about school" when they were crying three months ago has not changed their mind: they have stopped fighting. The phrase protects against failure, it does not signal an absence of anxiety.
Partial forms, not to be missed
School refusal almost never begins with total absence. It begins with partial forms, and that is where it should be caught.
Repeated lateness, particularly in the morning, often the first sign.
Shortened days: calls to the parents, leaving at the ten o'clock break, repeated visits to the school nurse.
Selective absences on one subject, one day of the week, one activity — sport and the canteen come first.
Presence without participation: the pupil is there, says nothing, hands nothing in, keeps to themselves. This is a refusal in the making, and the school sees it before anyone else. A pupil who comes to class every day but consistently does not speak there, while speaking normally at home, is more likely to have selective mutism: this is an anxiety disorder with its own protocol, conducted with the parents and the teacher, and Treating selective mutism in children: a therapist's manual describes it.
What school refusal is not
It is not laziness, and it is not a whim. That is the sentence to say to the parents in the first session, and it will need repeating.
It is not proof that the school is bad. Sometimes it is, and sections 10 and 35 deal with that. But looking for a culprit in the school before assessing delays the return.
It is not a diagnosis. One does not treat "school phobia": one treats what, in this particular young person, makes school inaccessible.
5. What the refusal is for: the four functions
Functional analysis is the most useful tool in this manual, because it gives the target directly. The question is not "why does he not go" but "what does not going give him, right now".
Four answers, which can combine. They restate, in different words, the functional model of Kearney and Silverman (1990).
Function 1: avoiding what triggers diffuse distress
The young person cannot say what frightens them. It is the building, the atmosphere, the noise, the crowd, the idea of being there. This function is frequent in younger children and in children with autism spectrum disorder.
What this changes. Exposure works through places and durations: coming to collect an exercise book, standing ten minutes in the empty playground, entering by a less busy door. You do not ask them to explain before you expose.
Function 2: escaping social or evaluative situations
The young person avoids precise moments and knows which ones: speaking up, entering late, the canteen, changing rooms, assessments, break time.
What this changes. Exposure works through situations rather than durations: a hierarchical list, as in a social anxiety protocol. Session 9 is devoted to it.
Function 3: obtaining the presence of a loved one
The young person seeks to stay with the parent, or not to be separated from them. This function dominates before eight, but is found well beyond, and it sometimes works on both sides: the parent also finds it hard to let go.
What this changes. The work is done as much with the parent as with the child. Sessions 3 and 10 carry that part, and separation is treated in steps like everything else.
Function 4: obtaining something more pleasant elsewhere
The day at home offers what school does not: screens, sleep, games, freedom, friends who are not in school. This is the function that should make you go back to section 3: if it dominates and there is no anxiety, this is not the programme.
What this changes. When it is added to an anxious function — a very common case after a few months — you treat both: exposure on one side, and on the other the fact that the day at home must stop being better than the day at school. This is not a punishment: it is the removal of an advantage that works against the young person.
How you identify the function
By what happens immediately afterwards. What does he do in the hour after the decision to stay? Go back to sleep? Stay glued to the parent? Pick up the console?
By what exactly is avoided. A young person who goes to school on Wednesday but not on Tuesday is not avoiding school: they are avoiding something about Tuesday.
By what soothes. If the parent's presence is enough, function 3 is in play. If nothing soothes until the day is cancelled, look at functions 1 and 2.
By what the school reports. A pupil who is fine as soon as they are in class is not fleeing the class.