– Elizabeth Deckler, MD1,2,3, Stephanie Rohrig, PhD2,3, Anthony Puliafico, PhD1,2
– Columbia University Medical Center, NewYork-Presbyterian Hospital, Weill Cornell Medical Center
What is School Avoidance?
School avoidance refers to a young person missing school due to anxiety or another mental health concern. School avoidance is different from truant behavior, when a student misses school without a lawful or valid excuse, and school withdrawal, when a parent holds a child back from school. School avoidance can be very distressing for children and their parents. Frequent school absence puts the child at risk of falling behind both academically and socially. School avoidance is a clinical concern that pediatricians and child and adolescent providers see regularly.
School avoidance is not a diagnosis, but rather a behavior that is often associated with mental health symptoms. It is typically seen in children with obsessive-compulsive disorder, social anxiety disorder, separation anxiety disorder, generalized anxiety disorder, and panic disorder, among other psychiatric conditions. This is expected because going to school triggers the exact discomfort children with these conditions try very hard to avoid. Children with social anxiety may fear interacting with peers and teachers. Those with separation anxiety fear leaving their parents. Children with generalized anxiety or panic disorders worry that their symptoms will flare up while at school.
How are OCD and School Avoidance Related?
Many children struggling with obsessive-compulsive disorder experience some degree of school avoidance. Obsessive-compulsive disorder, or OCD, is a mental health condition characterized by frequent intrusive thoughts, images, or urges (obsessions) and repetitive acts or behaviors intended to ease the anxiety caused by the obsessions (compulsions). A 2025 study published in Child Psychiatry & Human Development examined the relationship between OCD and school avoidance. The study, which took place in Sweden, included 385 children with OCD. At their first visit, 22% of the 385 children were attending school only partially or not at all. The study found that after these children were treated for OCD, more than half of them were able to return to school. The high degree of school avoidance in children with OCD, as well as the improvement in school attendance with OCD treatment, highlights the relationship between the two conditions.
What Does School Avoidance Look Like Within OCD?
School avoidance looks different in every child. Common reasons for school avoidance among children with OCD have included obsessions relating to school performance, compulsions that interfere with the child’s ability to get to school, and contamination of school bathrooms. A prolonged morning ritual, anxiety about using public transportation, and embarrassment over performing compulsions in a public setting are also commonly reported.
The following case example illustrates how school avoidance can develop in a child with OCD.
“Molly is a 15-year-old adolescent in 9th grade at her local high school. She earns good grades, participates in multiple extracurriculars, and plays soccer on her school’s team. She was diagnosed with OCD in fifth grade after her teachers noticed that she felt compelled to open and close her locker exactly four times whenever she used it. She was able to successfully treat her obsessions and compulsions with exposure and response prevention therapy (ERP). However, several years later, her OCD symptoms returned and became more severe. Homework that would usually take two hours to complete now took six. Molly spent hours proofreading her essays for errors until it felt “just right,” checking over her math homework exactly four times, and repeatedly reviewing her online homework portal to confirm that her assignments were uploaded. She knew that the double checking was excessive, but she struggled to stop. Molly also had an intense fear of germs. Using the bathroom at school became a struggle. She noticed that every time she entered the school bathroom, she needed to wash her hands for ten minutes to help her feel safe from the germs.
After two months of struggling with these compulsions, Molly started avoiding school. At first, she missed about one day every two weeks. But after a few weeks, she was missing several days per week. To Molly, staying home felt easier than facing anxiety-provoking situations at school. Once she started falling behind in her schoolwork as a result of missing class, she found it even more difficult to return. The thought of explaining her absences to teachers and peers, as well as the incomplete assignments piling up, made Molly feel like it would be impossible to return.
Molly’s experience is surprisingly common. The relationship between obsessive-compulsive disorder and school avoidance is seen clinically and is well established in the literature. However, practical guidance on preventing school avoidance in children with OCD, and helping children who are already avoiding school return, can be hard to find.
What Can We Do? Recommendations for Parents:
Parents play a significant role in preventing school avoidance in their children. A major aspect of OCD treatment is parental education on limiting accommodation. Parental accommodation refers to changes in routines or behaviors made to reduce a child’s distress. Examples of this include helping the child perform compulsions, planning meals around foods that the child sees as safe, and allowing the child to stay home from school due to their anxiety. If a child with OCD starts avoiding school for any reason, parents should tell their treating clinician as soon as possible.
It may feel easier to allow children to miss school when anxious, but this is counterproductive. Parents need to set limits around missing school. We recommend that parents limit children’s access to screens while they are home from school. Parents can also set clear limits, such as not allowing preferred after-school activities on days when the child does not attend school. Children should view staying home from school as boring.
Parents should also validate their child’s anxiety. OCD is a serious mental health condition that causes significant distress. When children express their worries about school to parents, they should listen, ask follow-up questions, and relay their understanding and care for the child. However, parents should be careful not to reassure the child. Reassurance seeking is a common behavior in OCD, and children with OCD struggle with uncertainty. Seeking reassurance is a form of compulsion. For children to improve their OCD symptoms, they need to practice experiencing uncertainty without reassurance. Examples of reassurance seeking include asking a parent if they believe the school bathroom is clean, having a parent confirm that they performed their rituals correctly, and asking if they think they are going to fail an upcoming quiz.
Exposure and response prevention, a critical part of the treatment for OCD, involves exposing children to places, thoughts, or situations that trigger their obsessive fear. The child then resists the urge to perform a compulsion. This type of therapy is challenging. Over time, this exercise decreases the fear and anxiety associated with the trigger. Children can participate in exposure and response prevention at school. If the child’s obsessive fear involves school performance, attending school and completing assignments exposes them to that trigger. If germs are an obsessive fear, using the bathroom at school is a helpful exercise in ERP. We recommend parents recognize the difficulty of this type of therapy and praise the child for facing triggers at school.
What to Expect From Your Child’s Therapy
The first step in treatment is evaluating current OCD symptoms. Your clinician will do a thorough assessment of your child’s obsessions and compulsions, particularly those related to attending school. If this is the first time your child is receiving treatment for OCD, your clinician will likely recommend a combination of exposure and response prevention therapy and medication, as research has shown this to be the most effective approach. It is also common for school avoidance to emerge in children who have already been undergoing treatment for OCD. In that case, your child’s therapist will assess for changes in the condition that may warrant a different treatment plan.
The most important part of therapy for school avoidance is school reentry. Your therapist will work with you and your child to create a plan for returning to school. School reentry plans look different for every child. They can range from going back to school full time immediately to seeing the guidance counselor one day, attending one class the next day, and slowly working up to a full school day. Some children need more support returning to school, and in these cases, your therapist may recommend utilizing a higher level of care. Higher levels of care include partial hospital programs and intensive outpatient programs. Partial hospital programs and intensive outpatient programs are forms of mental health treatment where the patient lives at home but attends a treatment program during the day. At these programs, your child will meet daily with providers such as psychiatrists, therapists, and social workers experienced in treating school avoidance.
How to Advocate for Your Child in School
Schools can be invaluable partners in treating your child’s school avoidance. Parents should request that the school designate a “go-to” person for the student to meet with if they are struggling with mental health difficulties at school. This allows the child to see school as a safe place to experience OCD symptoms. Parents should also ask the school to implement the reentry plan the child developed with the therapist. We recommend parents work closely with their child’s teachers to manage missing assignments and prevent falling behind academically.
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