What is emotional based school avoidance?
Emotional Based School Avoidance (EBSA) is a term used to describe a child or young person who has severe difficulty in attending school due to emotional factors. This can result in prolonged absences from school.
EBSA can present differently across individuals, but can show as:
- low or intermittent attendance
- high sensitivity or reactivity
- low mood and anxiety (fear of talking to teachers, fears around academic performance)
- social isolation
- signs of emotional distress that affects their ability to function at school, such as difficulties forming relationships with teachers and peers
- developmental differences that fundamentally shape perception and action in ways that cause significant challenges in emotional self-regulation and social functioning (autistic spectrum disorder, ADHD).
What isn’t EBSA?
It is crucial to have a clear and accurate understanding of EBSA to enable accurate identification of children or young people experiencing EBSA. There is a clear difference between those children or young people that are absent from school as a result of EBSA as opposed to parentally condoned absence (where a caregiver deliberately keeps or supports keeping a child or young person away from school for various reasons) or truancy, which is linked to non-anxiety-based absenteeism.
For situations such as this there are other routes of support and challenge that schools should take.
Why does EBSA happen?
EBSA can occur suddenly or develop gradually over time. Behaviours can also range from occasional reluctance to attend school to complete avoidance resulting in non-attendance. EBSA should not be thought of as a deliberate act of defiance as it is a complex issue with no single cause.
Reasons are often complex and multi-faceted across environmental factors (both at home and school) as well as individual child factors.
Any identified factors are unlikely to be static and fixed. What led to the initial school avoidance may not be what leads to persistent avoidance and non-attendance. What appears to be the cause of the issue may be the consequence.
Risk factors
There are a number of risk factors that can influence EBSA. These can include, but are not limited to, difficulties with managing and regulating emotions, low levels of self-confidence or self-esteem, high levels of family stress, relationship difficulties or academic demands. It is often the interaction between risk factors (across school, family and child or young person) that results in EBSA behaviours.
Resilience factors
While risk factors have been identified that place children at greater risk of EBSA, it is important to also consider, identify and build areas of strength or resilience available for the child, family and school. These resilience factors help to protect children and young people from maintaining EBSA behaviours, and promote successful school inclusion. Resilience factors can include, but are not limited to, emotion regulation strategies, motivation for change, willingness to work in partnership and an openness and commitment to trying to understand how the child or young person may be different and how this may affect them at school.
Push and pull factors
Risk and resilience factors can also be separated into push and pull factors. EBSA is most likely to occur when the risks overwhelm the resilience, and when the pull factors (that encourage school avoidance) take over the push factors (that encourage school attendance).
Anxiety
EBSA is often associated with feelings of anxiety in children and young people. Think of anxiety as the brain's alarm system being overly sensitive (very sensitive to breaking news). It's constantly guessing that something bad might happen, even when there is no real danger. It's like your body sending a red alert that something is not right (an error), but you're not exactly sure what the problem is. This could make a child or young person feel worried, nervous, or scared more frequently than usual. It's like their brain is seeing shadows in the dark and interpreting them as monsters, even though they are safe in their bedroom.
For children and young people who are going through this, these feelings might be so strong and unpleasant that they start to worry about how to make them less intense. Just like how you might feel nervous before a big test or game, it's normal for everyone to feel anxious or unsure at times. But for children and young people who struggle going to school because of their anxiety or experience of error, these feelings are not just a little bit nervous or unsure – they are very intense and uncomfortable and frequently uncontrollable.
Some children and young people experience such heightened levels of anxiety that it negatively impacts on their ability to attend and cope in school. Children and young people's avoidance of school reflects an attempt to preserve emotional security by shielding themselves from the stress, threats or social isolation they feel at school. Their avoidance may increase the certainty of feeling better away from stress and reduce the uncertainty about dealing with challenges at school. However, it also makes it increasingly difficult to return because it strengthens their beliefs about experiencing unpleasant feelings, which cause much distress and limits the opportunities to gradually overcome their difficulties. Moreover, the social network weakens, the academic gaps grow, and the fear of returning to school takes over. The complex context of school feels less and less safe and predictable as a result.
Anxiety may be the triggering, but also a maintaining factor of EBSA. The greater the avoidance of situations that cause fear or distress, the more difficult it will become to deal with it. With each individual situation, it is therefore crucial for schools and involved agencies to work together with the child or young person and their family and as early as possible to understand why the child or young person is reluctant to attend school. Lincolnshire’s Emotional Based School Avoidance (EBSA pathway) enables this to happen.
Lincolnshire EBSA pathway
When attendance is compromised because of EBSA, or indeed any medical issue, then there is a statutory duty for both school and local authority to deliver education, which can lead to a lack of clarity in relation to roles and responsibilities.
Section 100 of the Children and Families Act, 2014 places a duty on schools to make arrangements for all pupils with medical conditions in terms of both physical and mental health. Whilst section 19 of the Education Act (1996) requires local authority to arrange suitable (so far as health allows) full-time (if suitable) education for children who would otherwise not receive education because of their illness. Caselaw has established that a local authority will have a duty to provide alternative education if there is no suitable education available to the child which is reasonably practicable for the child to access.
The 1996 Education Act (section 7) also places a legal responsibility upon parents or carers to ensure that their child receives an appropriate, full time and effective education (suitable to their educational needs).
In England, the vast majority of parents fulfil their parental responsibility in relation to education by putting their child on a school roll, and ensuring that they attend regularly. However, if a child who is on a school roll and fails to attend regularly then it is possible that the parents will have committed an offence contrary to s444 Education Act 1996, unless one of the four statutory defences apply.
Lincolnshire’s EBSA Pathway clarifies what schools can expect of the local authority and what the local authority must expect from schools in relation to these duties. This, in turn, guides all stakeholders, not least children and families, in understanding what support they should expect to receive, when, where and from whom.
The EBSA Pathway is a graduated response (follows an assess, plan, do, review cycle) that is focused on:
- meaningful and robust early intervention through effective whole school systems.
- clear understanding of individual needs and contexts.
- collaborative, person-centred working with parent and carers and the child or young person.
The pathway considers each stage of EBSA, from indicators of risk of EBSA, through early indicators of EBSA to EBSA occurring, and provides steps to be taken.
The EBSA pathway is a wraparound approach of proactive support. Throughout this is the emphasis on the need for a return to school, alongside support strategies and interventions and adaptations within the school and home environment.
Initial Steps: early intervention and effective whole school systems
School, through their key role in the identification of children and young people who are currently experiencing or are at risk of EBSA, will have effective whole school systems to support young people. This will include being vigilant to early indicators and using a thorough assess, plan, do and review cycle that places children and young person at the heart.
The initial steps within the EBSA pathway support schools to take a preventative measure towards EBSA, with a focus on early intervention and prevention. It is important to identify the early warning signs of EBSA. If unaddressed, the EBSA behaviours can become entrenched making it more difficult to intervene once the child or young person has been out of education for some time.
If a parent or carer has any concerns about early warning signs of possible EBSA then a discussion should take place with the child or young person’s school. This will allow school to explore these worries at the earliest opportunity to ensure the right support is offered that prevents these worries growing.
Early help assessment
These conversations may involve school completing an early help assessment to gain an understanding of the whole picture. This will involve understanding the worries that may be impacting on the child’s well-being and the current strengths that can be built upon to address the worries, as well as who is in the child or young person’s support network and what needs to happen next to support the child.
This will help to determine if the child or young person is displaying EBSA as opposed to truancy or parentally condoned absence so that the appropriate support can be put in place. It will also help determine the next steps, such as a Team Around the Child, to avoid those early warning signs deteriorating into EBSA.
Healthcare plan
Individual healthcare plans can help to ensure that schools effectively support pupils with medical conditions, in terms of both physical and mental health. They provide clarity about what needs to be done, when and by whom. While not all children and young people will require a healthcare plan, they will often be essential, such as in cases where conditions fluctuate or where there is a high risk that emergency intervention will be needed, and are likely to be helpful in the majority of other cases, especially where medical conditions are long-term and complex. The school, healthcare professional and parent should agree, based on evidence, when a healthcare plan would be appropriate.
If a parent or carer has any concerns that a healthcare plan may be needed then a discussion should take place with the child or young person’s school. This will allow school to explore this further and come to an agreement.
Next steps: assess and plan
Assess:
For the majority of children and young people, robust whole school systems and preventative steps through early intervention will ensure needs are met and avoid them developing into EBSA behaviours. For those children and young people that need further support the steps within this Pathway continue the thorough assessment that leads into a robust plan as part of the assess, plan, do and review cycle, with the child or young person at the centre.
For any intervention or support plan to be successful, it is essential to gain an understanding
of the various aspects at the core of the child or young person’s emotional distress and/or social isolation that may be causing and maintaining the EBSA behaviours. It is vital that children and young people’s behaviours are understood in the full complexity of their lives as unique human beings.
It can be tempting to try and identify a simple reason and simple solution for the EBSA behaviour. However, as identified earlier, EBSA is complex and often an interaction of several factors. Therefore, for assessment to be meaningful it will need to be multi-faceted and use a mixture of creative tools for drawing out views. School will lead on this and the gathering of information from the child or young person, their family, key adults in school and involved professionals.
The important element is the quality, depth and richness of the information that is gathered. This allows the areas of concern to be broken down into smaller more manageable parts, identifying how they interact with and contribute to the EBSA behaviours and lead to robust strategies to be implemented. This can be revisited as new information becomes available or the child or young person’s situation changes.
Plan:
Once all the assessment information has been gathered and considered fully, school will draw it together into an EBSA support plan. This is a structured and adaptable plan that involves the child or young person, the family, school and any involved professionals to develop and implement personalised interventions. The plan will address the identified needs of the child or young person both at home and school, ensuring that the strategies effectively target the unique challenges.
The EBSA pathway supports schools to implement a plan that is individualised to the child and linked to the factors that have been identified through assessment as contributing to EBSA. Intervening at both school and home level with a range of strategies.
Further steps: do and review
Do:
Once the initial EBSA support plan is drawn up it will be put into action. This will require ongoing working from everyone involved with the child or young person at the centre to ensure they have ownership of the plan. There may be bumps when carrying out the agreed plan and when this happens there should be a commitment from everyone to find solutions.
The child or young person is likely to be more unsettled at the beginning of the plan and it is key that school and the family need to work together to show a consistent approach to managing heightened emotions and anxieties. The plan should be for a gradual and small step reintegration. Early home visits by a designated member of staff from school, ideally with whom the child or young person has a positive relationship with, will support a sense of connection and ‘school belonging’.
Review:
Once the EBSA support plan is put into action it needs to be continually monitored and adjusted, as needed, through regular planned reviews, consistent communication, realistic goal setting and ongoing collaboration between the child or young person, their family, school and any involved professionals.
It is important to ensure all the agreed resources and support are in place at all times for the child or young person and that there continues to be good communication with the child or young person, family and any involved professionals. Remember to give time for the strategies and approaches to work and achieve the agreed outcomes.
Within the regular reviews the EBSA support plan needs to be updated as part of the ongoing process of evaluating and refining the interventions. This will involve looking at what is working well and any aspects that need changing that build on the positives. Consistency is key. Ensuring that all agreements are consistently followed until the next review and all parties (home, school and professionals) continue to work together with a consistent approach. It is also important to continue to be realistic and break down larger goals into small, achievable steps. High aspirations can be good, but an overly ambitious plan is likely to fail. The plan should continue to aim and plan for a gradual and graded reintegration.
Within the ongoing assess, plan, do and review cycle it will be important to revisit the assessment and planning steps to further develop the Plan as situations develop and change. It is crucial to keep revisiting these at each review to ensure all the planning is focussed on the appropriate and current information.
Mental health involvement
Evidence tells us that early intervention, when issues arise, helps to prevent mental health problems developing in the future. There is a range of available support from Lincolnshire’s mental health teams that is focussed on providing children and young people with early interventions to prevent emotional wellbeing worries escalating into mental health concerns. This should be built into school’s effective whole school systems.
Healthy Minds provides emotional wellbeing support for children and young people up to 19 years old (or 25 years old for young people with SEND or are a care leaver). The support offered is based on cognitive behavioural therapy (CBT) techniques. They offer self-help, workshops, virtual groups and one to one sessions. Mental health support teams (MHST) are an expanding service designed to help meet the mental health needs of children and young people in selected education settings. Teams are made up of clinical lead practitioners and education mental health practitioners (EMHPs). They work collaboratively with selected education settings.
If a parent or carer is worried about their child’s mental health, or a young person is concerned about their own mental health, they can discuss these with school. Alternatively, Here4You offers an advice and self-referral line for parent and carers of children, and for young people (aged 13 or over), who are struggling with their emotional or mental health and are not currently being supported by Healthy Minds, mental health support team or Child and Adolescent Mental Health Service (CAMHS). There is an online self-referral form and access to information about online workshops, websites and tips from young people to young people.
In relation to the EBSA pathway, it is important not to expect too much too soon, but where there has been limited progress it may be appropriate to invite a mental health practitioner to support the review of the support plan. School will be able to do this as appropriate.
Pupil reintegration team (PRT)
The pupil reintegration team provides a wide range of support to schools in relation to EBSA.
Their EBSA caseworkers are able to support with identifying signs of EBSA, offer consultations, training and advice, share good practice, guide through the implementation of robust and meaningful cycles of assess, plan, do and review and signpost to alternative agencies for advice and information.
At any stage within the EBSA Pathway school can contact an EBSA caseworker from the pupil reintegration team to support the pathway. This can involve:
- support with identifying children and young people exhibiting EBSA and provide advice and guidance through consultations
- attend scheduled review meetings, or provide advice throughout the assess, plan, do, review stages
- recommend suitable targets for children and young people and support with implementing appropriate strategies and interventions
- provide advice around gaining the child or young person’s voice and ensuring that they remain central to the process
- identify, share and promote good and innovative examples across schools
- signpost to alternative agencies for further advice and guidance
- provide case supervision to settings experiencing a high level of EBSA cases
- provide advice prior to completing a referral to medical support panel (MSP) and support with implementing feedback.
They can be contacted via email or telephone: 01522 555798 (North) or 01522 555816 (South)
Medical support panel
Lincolnshire children's services hold as a fundamental principle that wherever possible all children and young people, including those with health needs, should be supported to access their learning in their substantive school alongside their peers and this should include access to a broad and balanced curriculum, suitable for their age ability and aptitude.
Therefore provision for children or young people who experience a period of ill health, be that physical illness or poor mental health, is a responsibility that encompasses all education professionals, including those working in schools and the local authority. Each has a part to play in supporting children and young people to access their statutory right to education.
Section 100 of the Children and Families Act, 2014 places a duty on schools to make arrangements for all pupils with medical conditions in terms of both physical and mental health. This includes having a policy in place that clearly sets out how school will support and provide for pupils with medical needs. This policy should include the nature and range of available support, the process for early identification, reasonable adjustments to the learning and physical environment and how pupils can access this support. Schools should utilise all resources at their disposal, including the pupils premium where applicable, to maintain that pupil in school through the development of bespoke learning packages, including the use of virtual learning platforms and blended learning opportunities.
Section 19 of the Education Act (1996) requires us to arrange suitable (so far as health allows) full-time (if suitable) education for children who would otherwise not receive education because of their illness. The courts have considered the circumstances where the section 19 duty applies. Case law has established that a local authority will have a duty to provide alternative education under section 19 if there is no suitable education available to the child which is reasonably practicable for the child to access. Therefore there will be a wide range of circumstances where a child or young person has a health need but will receive suitable education that meets their needs without the intervention of the local authority. For example, where the child can still attend school with some support or where the school has made arrangements to deliver suitable education outside of school for the child.
The 1996 Education Act (section 7) also places a legal responsibility upon parent and carers to ensure that their child receives an appropriate, full time and effective education (suitable to their educational needs).
Medical support panel
Lincolnshire’s medical support panel (MSP) is a multi-agency panel that considers the needs of pupils in order to arrive at a decision about how suitable education might be provided
Referrals to medical support panel are submitted by a pupil’s school or if a pupil is not on the role of a school, via an authorised officer within the local authority (pupil reintegration team or the inclusion and attendance team). The medical support panel is evidence based and will consider pupil’s needs holistically.
Medical support panel takes place fortnightly during term time and considers the referral paperwork and supporting evidence that has been submitted. The panel consists of representation across attendance, inclusion, mental health, early help and Pilgrim Hospital School.
EBSA pathway
Where, despite school robustly following the steps within the EBSA pathway, there continues to be a barrier to attending school a referral to the medical support panel may be appropriate. They will undertake a review of the support and interventions put in place by school and consider what further steps need to be taken to ensure receipt of a suitable education because of ill health. The panel’s outcome will advise regarding what further steps, strategies and support school can and should be robustly implementing to ensure continued access to suitable education. One of the further steps may be access to a short-term period of intervention at Pilgrim Hospital School. This would be a dual placement and focussed on working with the pupil’s school to support the pupil’s timely transition back to their school.
A referral to medical support panel requires school, or local authority officer where the child or your person is not on the role of a school, to complete the referral form and provide clear evidence of the school’s application of the EBSA pathway. Where possible the referral should also provide supporting evidence from a medical professional.
Physical health needs
Where a child or young person has significant physical health needs which, despite reasonable adjustments from school, prevent them from accessing their usual place of learning for 15 school days or more, schools should complete the referral to the medical support panel. Though not an exhaustive list, this would include pupils who have a significant physical illness, have been an inpatient and require support upon discharge, have had major invasive surgery or are undergoing oncology treatment.
The referral should be supported by medical evidence from an appropriate medical professional leading on the treatment for the pupil that demonstrates that the pupil is unable to access suitable education at their school.
The panel’s outcome will advise regarding what further steps, strategies and support school can and should be robustly implementing to ensure continued access to suitable education. One of the further steps may be access to a short-term period of dual registration with Pilgrim Hospital School. This would be a dual placement and focussed on working with the pupil’s school to support the pupil’s timely transition back to their school.
Pupils with Education, Health and Care (EHC) Plans
Where a child or young person with health needs also has an EHC plan, their access to education is enshrined within their EHC plan. A pupil with an EHC plan can also experience periods of ill health, therefore schools should follow these routes in the event that a pupil with EHC plan exhibits these challenges. This must also involve close liaison with the SEND caseworker to ensure that the EHC plan resource is utilised appropriately to meet needs.
Where there are concerns about the pupil's provision, schools should always liaise with the SEND team and arrange for an annual review meeting. Where the annual review identifies that the current setting is unable to meet needs consideration must be given as to what the long term provision requirements are. A referral to medical support panel is not appropriate simply because the pupil is not able to engage with their mainstream school placement. The basis for all referrals including those with EHC plan, is that the pupil is unable to access their current setting, not because the current setting cannot provide for the pupil's needs.
Lincolnshire's medical needs policy
The medical needs policy sets out how we will meet our statutory duty to provide full-time education for children of compulsory school age who, because of illness, would not receive suitable education.