Starting school, separation worries and school refusal: what the research supports

Background: starting school, separation worries and school refusal

Starting or changing school is one of the most common hard moments of childhood. Most children worry a little and most settle. The research questions are which children do not, what helps the transition, and what works when worry turns into avoiding school.

Separation worries are developmentally normal. The NHS describes separation anxiety as very common from about 6 months to 3 years, easing for most children around age 2 to 3 (NHS, 2026). In a Quebec cohort of 1,933 families followed from 18 months to 6 years, 60.2% of children had persistently low separation anxiety, and symptoms fell substantially by age 6 in every group except a small one (6.9%) whose anxiety started high and kept rising; only that group predicted separation anxiety rated by teachers at age 6 (Battaglia et al., 2016). Separation anxiety disorder is qualitatively different: an abnormal reaction to separation that interferes with daily life. An older review put its prevalence at 4 to 5% of young people and reported school refusal in about three-quarters of affected children (Masi et al., 2001).

School refusal is not truancy. Researchers now distinguish four kinds of school attendance problem. In school refusal the child is reluctant or refuses to attend because of emotional distress, does not hide the absence from parents, and parents have tried to get the child to school. Truancy is absence without permission, usually hidden from parents. School withdrawal is when parents keep the child at home or make little effort to get them there, and school exclusion is absence caused by the school, for example when it fails to accommodate a child's needs (Heyne et al., 2019). In the UK the term emotionally based school avoidance (EBSA) is widely used for the first kind; in England, absences rose after the COVID-19 pandemic (Lester & Michelson, 2024). School refusal is estimated to affect about 1 to 2% of young people, with higher rates among children referred to mental health services (Maynard et al., 2015).

Why it happens. A systematic review found cross-sectional links between school refusal and separation, generalised and social anxiety and specific phobias, but little longitudinal research (Finning et al., 2019). Kearney and Silverman's widely used functional model asks what the absence does for the child: avoiding distress, escaping social or evaluative situations, gaining attention, or gaining rewards outside school. Its structure is not consistently supported, it leaves out factors such as bullying, sleep and learning difficulties, and its treatment utility rests on case studies and one small non-randomised study (Heyne et al., 2019). Absence matters in its own right: unexcused absence is more common than the major childhood behaviour disorders and is a risk factor for later psychiatric and economic problems (Kearney, 2008). Parent factors linked with school refusal include parental mental health, family functioning and some forms of overprotection, although the evidence is sparse and dated (Chockalingam et al., 2023).

How the research has been done

Three bodies of research meet here. Studies of school transitions are mostly large observational cohorts, which show associations rather than causes, plus varied evaluations of universal programmes (Donaldson et al., 2023). Studies of school refusal treatment are few: a handful of randomised controlled trials (RCTs), each with roughly 20 to 150 young people, mostly aged between 5 and 16, comparing cognitive behavioural therapy (CBT) with a waiting list, an alternative treatment or usual care, and measuring attendance and anxiety (Maynard et al., 2015); (Johnsen et al., 2024). Studies of child anxiety in general are larger and include cluster RCTs, which randomise whole schools, and non-inferiority trials, which test whether a simpler treatment is no worse than the standard one. Our methods glossary explains these designs and effect sizes (Hedges' g).

What the reviews and trials found

Transition practices

In a US national sample of 17,212 children in 992 schools, the more transition practices a school used in the autumn of kindergarten, the higher children's achievement at the end of the year, especially for children from lower- and middle-income families; part of the link ran through greater parent involvement (Schulting et al., 2005). A later national study of 4,900 children found teachers used three practices on average, most often outreach to parents and classroom visits. More practices predicted more prosocial behaviour but not better attention or academic skills; parent-focused practices were the ones linked to academic gains, and immigrant, minority and urban children had teachers who reported fewer practices (Cook & Coley, 2017). Both studies are correlational.

A systematic review of universal programmes to support mental health across school transitions found 34 papers on 24 interventions. Social outcomes changed more readily than behavioural ones, and psychological outcomes were mixed; programmes for younger children focused on parenting and the school environment (Donaldson et al., 2023). For autistic pupils, a review of 27 studies found the most useful strategies were helping the child adjust to the new setting, individualising support, explaining the process to parents and good school–school and school–home communication (Nuske et al., 2019).

School refusal: reviews and trials

The Campbell systematic review (also published as a journal article) found only eight rigorous studies (435 young people), seven testing a form of CBT. Treatment improved attendance compared with controls (g = 0.54, 95% CI 0.22 to 0.86) but had no significant effect on anxiety (g = 0.06, 95% CI −0.63 to 0.75). Most studies compared CBT with another, sometimes similar, treatment; most had risks of bias; and only one reported longer-term comparative outcomes (Maynard et al., 2015); (Maynard et al., 2018). A 2025 meta-analysis of four RCTs and eleven open trials (932 young people) reached a similar conclusion: against controls, CBT had a medium effect on attendance (g = 0.44) and no significant effect on anxiety or depression (Jakobsen et al., 2025). A practitioner review found little substantial advance since 2000, with confused definitions and too few rigorous trials (Elliott & Place, 2019).

Two points stand out. First, against a credible alternative the difference shrinks: in the attention-placebo trial both groups returned to school at similar rates, and still did not differ the next school year (Last et al., 1998). Second, work with parents and teachers matters: in the Melbourne trial, attendance appeared to improve faster when parents and teachers were trained than when children were seen alone, though all groups were similar by follow-up (Heyne et al., 2002). A co-designed online programme for parents of children aged 5 to 11 with emerging EBSA, supported by a non-specialist coach, was feasible with nine families and showed small to moderate reductions in avoidance and anxiety, without a control group (Lester et al., 2026). For severe cases, mostly adolescents, intensive programmes exist, with high-intensity graded exposure among their key ingredients, but outcomes are inconsistently reported (Ratnamohan et al., 2026).

Parent-led CBT and reducing accommodation

Trials of child anxiety in general give the strongest evidence for parent-delivered approaches. In a UK RCT of 194 children, guided parent-delivered CBT (four face-to-face and four telephone sessions) led to recovery from the main anxiety diagnosis in 50% of children, against 25% on a waiting list; a briefer version did not differ significantly from the waiting list (Thirlwall et al., 2013). In NHS services, brief guided parent-delivered CBT was no more effective than solution-focused brief therapy but likely cost-effective (Creswell et al., 2017), and an online, therapist-supported version was non-inferior to usual care in 444 families (Creswell et al., 2024).

Family accommodation means the changes parents make to spare a child anxiety, such as staying until the child calms, giving repeated reassurance or allowing avoidance. A meta-analysis found a moderate association between accommodation and anxiety severity on parent reports, varying with the share of children with separation anxiety or selective mutism in a sample (Iniesta-Sepúlveda et al., 2021). The SPACE programme works only with parents, helping them respond supportively while reducing accommodation. In a non-inferiority RCT of 124 children aged 7 to 14, SPACE was no less effective than child CBT and reduced accommodation more (Lebowitz et al., 2020); gains were maintained at 12 months (Etkin et al., 2026). An overview of 25 systematic reviews found most reported no difference between parent-only, child-only and family formats, although parent-only CBT tended to do worse in the direction of effects (Byrne et al., 2023).

Prevention for inhibited preschoolers and school-based screening

Inhibited, very shy preschoolers are at higher risk of later anxiety. In a trial led by Rapee, a six-session parent group (parenting skills, managing worried thinking and gradual exposure) reduced anxiety diagnoses at 12 months and at 3 years compared with no intervention or monitoring, although children's inhibited temperament itself did not change (Rapee et al., 2005); (Rapee et al., 2010). At 11-year follow-up, girls in the programme had fewer internalising disorders, while boys showed few differences (Rapee, 2013). A parenting group programme for inhibited preschoolers, Cool Little Kids, offered across the population through 307 Melbourne preschools, reduced internalising problems at one year but made little difference to anxiety disorders, and none by middle childhood; engagement was low, and benefits appeared mainly for children with anxious parents (Bayer et al., 2018); (Bayer et al., 2022).

Two English cluster RCTs published in 2026 tested screening in primary schools followed by online parent-led CBT. For children aged 4 to 7 at risk of anxiety, the intervention did not significantly reduce anxiety disorders at 12 months, although it improved all secondary outcomes (Reardon et al., 2026b). For children aged 8 to 9 who screened positive, more children in intervention schools screened negative at 12 months (61% vs 38%) on a brief parent questionnaire (Reardon et al., 2026a).

For whom and under what conditions

• Family circumstances. Transition practices were more strongly linked to outcomes for children from lower- and middle-income families (Schulting et al., 2005), yet some groups of children have teachers who offer fewer practices (Cook & Coley, 2017).
• Parent anxiety and engagement. Prevention appeared to help most when a parent was also anxious, and low attendance may explain why population effects faded (Bayer et al., 2018); (Bayer et al., 2022).
• Who is involved. Involving parents and teachers appeared to speed up the return to school (Heyne et al., 2002); a parent-only programme offers an alternative route when direct work with the child is not possible (Lebowitz et al., 2020).
• Age. School refusal trials mix primary and secondary pupils, so evidence specific to children under 8 is thin; long-term preventive effects differed by sex (Rapee, 2013).
• Autistic pupils. Individualised transition support and strong home–school communication are especially important (Nuske et al., 2019).

What this means in practice

• Prepare, concretely. Explain what will happen and why before a new school or class (NHS, 2026). Classroom visits and school contact with parents are the most common transition practices, and parent-focused ones were linked with better academic skills in a national study (Cook & Coley, 2017).
• Expect some worry, and watch the pattern. Clinginess at drop-off is common and usually fades. Worry that is very strong, getting worse or stopping a child doing things is the signal to act (NHS, 2026).
• Support without removing every challenge. Accommodation is linked with more severe anxiety (Iniesta-Sepúlveda et al., 2021). Acknowledge the feeling, show confidence that the child can cope and keep the routine, easing in with small steps where needed.
• Talk first, then take small steps. The NHS advises against forcing a child into a stressful situation before understanding what is causing the anxiety (NHS, 2026). Once the reasons are clear, graded exposure, with parents and school staff supporting each step, is a core ingredient of the programmes tested (Maynard et al., 2015).
• Make it a joint plan. Involve the class teacher or special educational needs coordinator, and look for school factors such as bullying or learning difficulties as well as anxiety (Heyne et al., 2019).
• When to get professional help. See the GP or school nurse if anxiety is severe, persistent or interfering with daily life (NHS, 2026), and promptly if absences mount. Researchers treat missing at least a quarter of school time over two weeks, two weeks of severe difficulty attending, or 10 days' absence in 15 weeks as problematic (Heyne et al., 2019). School refusal or physical complaints are often what first brings a child with separation anxiety to a clinician (Masi et al., 2001).

What this means for social stories and short personalised cartoons

Preparation materials fit the evidence on predictability and explanation. A practitioner article in the US early-years journal Young Children described teachers writing short, personalised social stories, often with photographs, to help a 2-year-old and a 4-year-old with drop-off and joining a new group; the authors describe both children becoming more comfortable, but no outcomes were measured (Briody & McGarry, 2005). Most research on social stories involves autistic children and specific behaviours, not school worries in general; see our reviews of the social stories evidence, social stories beyond autism and stories for big changes.

• What they can plausibly do. Make a new routine predictable, give adults and child a shared script for drop-off, and set out a small first step. A short cartoon of a child managing drop-off borrows from video modelling, studied mostly with autistic children learning specific skills, not anxious children starting school. Our free social stories and personalised cartoons aim at this kind of preparation; neither has been tested in a trial.
• What they cannot do. A story is not graded exposure, and it cannot fix a school problem such as bullying or unmet learning needs. Persistent school refusal needs a plan with the school and, often, professional help (Elliott & Place, 2019).
• A risk to avoid. Rereading a story many times to calm a child before every drop-off could become another form of accommodation. Use it to prepare and to mark progress, not to postpone the step itself (Lebowitz et al., 2020).

Limits of the evidence

• Transition research is mostly observational; schools using more practices may differ in other ways (Schulting et al., 2005).
• School refusal has few RCTs, most small, with mixed ages, unblinded ratings and short follow-up (Maynard et al., 2015).
• Definitions have long been inconsistent, which makes studies hard to compare (Heyne et al., 2019); (Elliott & Place, 2019).
• Attendance improves more reliably than anxiety, and it is unknown whether anxiety falls later with continued attendance.
• Social stories and preparation videos for starting school have not been evaluated in controlled studies.

Open questions for research

• Does a short social story or preparation video before school entry reduce drop-off distress in typically developing children? A randomised trial with teacher-rated settling and observed distress could answer this cheaply.
• Do preparation materials reduce anxiety, or do some families use them in ways that increase accommodation? Measuring accommodation alongside child outcomes would show which.
• Which transition practices matter most for inhibited or anxious children, rather than for children's achievement on average?
• What works for school refusal in children under 8, who are under-represented in trials?
• Does improved attendance lead to lower anxiety over the following year?
• Can school screening plus parent support prevent anxiety disorders in the longer term, and how can programmes keep families engaged?

Frequently asked questions

References

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Spotted an error, or know a study we should add? Email hello@calalunakids.com. Every study we draw on is in the research library; research terms are explained in our methods glossary.