Treatment for School Refusal: What Works and What to Expect

The best-studied treatment for school refusal is cognitive behavioral therapy (CBT) built around a gradual, planned return to school, usually with parents and school staff involved. In the main review of the trials, CBT-based treatment improved attendance. The research base is small, though, and results are more modest than many websites suggest, especially for teenagers.

School refusal is not a diagnosis. It is a pattern with different causes in different children, so a good plan starts with working out what is driving it for your child.

Assessment comes first

The American Academy of Child and Adolescent Psychiatry (AACAP) describes a good evaluation as "talking with the child, parents, and teachers, a doctor's visit to rule out physical causes, and figuring out what's really driving the avoidance."

The medical visit matters because stomachaches, headaches and nausea are common in school refusal, and the American Academy of Pediatrics lists an examination by your child's doctor as the first step. A clinician will then usually ask about:

• How much school has been missed: full days, late arrivals, early pickups or particular classes
• What mornings look like, and what happens at home on days your child does not go
• Anxiety, low mood, sleep, friendships and bullying, including online
• Learning difficulties, attention problems, autism or a medical condition not yet identified
• Any thoughts of self-harm or suicide

Many clinicians also do a functional assessment, which asks what the avoidance does for your child. Christopher Kearney's model describes four functions: avoiding school situations that cause distress, escaping painful social or evaluative situations, seeking attention from important people, and pursuing rewards outside school. A provider may use a questionnaire with child and parent versions, the School Refusal Assessment Scale-Revised, to sort this out. Our guide on why kids refuse school explains the functions.

CBT with graded exposure

CBT for school refusal teaches coping skills, then moves your child back toward school in small, agreed steps. AACAP says it "has the strongest research support." Our gradual return-to-school plan shows what the steps can look like. Here is what that support consists of.

• The main review. Maynard and colleagues (2018) pooled eight studies with 435 children and adolescents. Across six studies of CBT-based treatment, attendance improved by a moderate amount by the end of treatment. Across the four that measured anxiety, the effect was close to zero and not statistically significant.
• CBT against a waiting list. A 1998 randomized trial of 34 children aged 5 to 15 found that four weeks of child CBT plus parent and teacher training improved attendance, with gains held at three months.
• CBT against educational support. Another 1998 trial of 56 children compared 12 weeks of CBT with an educational support control. Both were "equally effective at returning children to school."

Put together: attendance improved with structured help in these trials, but it is not settled that CBT techniques are the ingredient that does it. In the review, attendance improved without a clear change in anxiety by the end of treatment. The review authors called for longer follow-up to see whether anxiety drops later.

They were frank about limits too. There were few studies, most lacked adequate blinding, and only one reported follow-up for both groups, so there is not enough evidence to say whether gains last.

Parent training and reducing accommodation

In a 2002 randomized trial, 61 children aged 7 to 14 received child therapy, parent and teacher training, or both. Right after treatment, child therapy alone looked least effective for attendance. By the follow-up at about four and a half months the three groups were equal, and combining the two was no better than either one.

Parent training usually covers how to respond to morning distress calmly, how to reward attendance, and how to make a day at home less rewarding than a day at school. It never means physical force or punishing a child for being anxious. See parent training for how sessions work.

SPACE and family accommodation

Family accommodation means the ways parents change their own behavior to ease a child's anxiety in the moment, such as answering repeated reassurance questions or picking a child up early. It is a natural response. One research review reports it may have a harmful effect on the course of anxiety.

SPACE (Supportive Parenting for Anxious Childhood Emotions) is a parent-based program developed by Eli Lebowitz at the Yale Child Study Center. Parents attend the sessions; in most cases the child does not.

What the trial studied, exactly: a 2020 randomized noninferiority trial assigned 124 children aged 7 to 14 with anxiety disorders to 12 sessions of SPACE or of child CBT. SPACE was noninferior on anxiety outcomes, which means not meaningfully worse, not better. The children had anxiety disorders, not school refusal. School attendance was not measured. No one was older than 14, and 83% of the sample was white. So this trial does not show whether SPACE works for school refusal.

DBT-informed approaches

Dialectical behavior therapy (DBT) teaches skills for tolerating distress and regulating strong emotion. Researchers at Rutgers adapted it for school refusal as DBT-SR, adding video coaching on school mornings.

The published evidence is a small open pilot with case examples and no comparison group. A related dissertation concluded the coaching needs testing with a larger sample and objective data. No randomized trial of DBT for school refusal was found in the research reviewed for this page. The case for DBT skills is a rationale, not a proven result.

Medication

Whether medication has a place is a decision for a prescriber such as a pediatrician or child psychiatrist. AACAP tells parents a doctor may recommend medication along with therapy, rarely medication alone. This is a summary of the trials, not advice.

• A 2017 randomized trial of 62 anxious school-refusing adolescents aged 11 to 16 compared CBT alone, CBT plus fluoxetine, and CBT plus placebo. Adding the medication did not improve attendance.
• A 2000 trial in school-refusing adolescents with both anxiety and major depression found imipramine plus CBT improved attendance more than placebo plus CBT. It is a single older trial, and 47 of the 63 adolescents who entered it completed it.
• A 2018 systematic review of seven trials with 306 young people called them "severely underpowered," found no significant improvement over placebo, and concluded the data are sparse.

School-based supports

Two of the trials above included teacher training, so school involvement is part of the tested package. AACAP notes a school can support a family's plan, including through a 504 plan or an Individualized Education Program if a child qualifies. See our guide to 504 plans and IEPs.

What this means for teenagers

Teenagers are the harder group. A 2014 paper by Heyne and colleagues states that the poorest treatment response is seen among older school refusers. In the 2017 adolescent trial above, all groups improved, yet attendance stood at about 54% through one-year follow-up and few participants were free of an anxiety disorder after treatment.

A CBT program adapted for adolescents was tested in 20 teens, with improvements in attendance and anxiety two months later. It had no control group, so it cannot show the program caused the change.

The practical reading: act early, because older students have shown the poorest response in the research. Involve parents and the school, since several of the trials included them. Expect progress in steps. Be cautious of anyone who promises a fast, full return.

Levels of care

Most treatment happens in weekly outpatient sessions. AACAP describes intensive outpatient programs (9 to 19 hours a week) and partial hospitalization programs (at least 20 hours a week) as options with more support while a young person still lives at home. Our guide on when outpatient therapy is not enough explains when to consider them.

Mountainside Behavioral Health provides the outpatient part: CBT, DBT and parent training for ages 8 and up and their parents, in Greenwood Village and by telehealth across Colorado. See school refusal support in Denver.

If your child talks about suicide or self-harm, do not wait for an appointment. Call or text 988, which in Colorado reaches the 988 Colorado Mental Health Line, or call 911 if there is immediate danger.

If your child talks about wanting to die, is harming themselves, or you are worried about their safety, call or text 988 to reach the 988 Colorado Mental Health Line (free, confidential, 24/7). If anyone is in immediate danger, call 911.

Frequently asked questions

Related reading

• Finding a school refusal therapist
• When outpatient therapy is not enough
• A gradual return-to-school plan
• School refusal in teenagers
• CBT for Teens: Helping Denver Adolescents Build Healthy Thinking Habits
• School refusal and school avoidance support

All school refusal resources →

This page is general education, not medical or legal advice, and it does not replace an evaluation by a licensed professional who knows your child. Laws, district policies and program details change; confirm them with your school district or the organization named.