School should feel safe, predictable, and manageable. For most pupils, most of the time, it does. But for a growing number of children and teenagers, anxiety can make the school day feel genuinely overwhelming, and when that happens, the first-aid room is often where it shows up first.
A pupil with a recurring stomach ache before PE. A child who keeps asking to go home. A teenager who is increasingly late, increasingly quiet, or increasingly absent. These situations are not always straightforward, and they are not always what they first appear to be.
In this issue of The First Aid Room, we explore school anxiety, Emotionally Based School Avoidance (EBSA), the relationship between anxiety and attendance, and how school staff can recognise when a pupil may need additional support.
Much like adults, children can feel anxious from time to time. Feeling worried or anxious is a normal part of growing up and can be linked to everyday experiences such as exams, friendship difficulties, new situations or changes at school.
In most cases, those feelings pass.
But anxiety becomes a concern when it is severe, persistent, or begins to interfere with a child’s day-to-day life.
Importantly, school anxiety isn’t a clinical diagnosis in itself. It is a broad term used to describe persistent worry, fear, or distress associated with school or aspects of school life, such as lessons, social situations, performance, relationships, or simply the act of being there. It can affect pupils of any age, any background, and any academic ability.
The scale of the challenge is significant. Mental health difficulties are increasingly part of the landscape schools are supporting, and a strong link between mental health and attendance has very much been established:
This does not mean every absence is caused by anxiety or mental health conditions, but it does highlight why attendance patterns can be an important part of understanding a pupil’s wellbeing – and why school staff are often well-placed to notice the early signs.
For some pupils, anxiety around school does not stay at the level of worry. It begins to affect whether they feel able to attend school at all. This is the territory of Emotionally Based School Avoidance (EBSA): a pattern where emotional distress makes attending school feel genuinely difficult, overwhelming, or even impossible.
EBSA is estimated to affect between 1% and 5% of school-aged children at any one time, though some local authority guidance suggests the figure may be higher, particularly since the Covid-19 pandemic.
Importantly, it is not the same as truancy. Pupils experiencing EBSA typically want to attend school. anxiety makes it feel impossible, not undesirable.
EBSA can be linked to social anxiety, bullying, academic pressure, separation anxiety, changes in routine, health conditions, or difficulties at home. Often, several of these factors overlap.
The pattern tends to follow a recognisable trajectory: anxiety increases before school, symptoms ease once the pupil is at home, attendance becomes inconsistent, and returning grows harder over time.
This cycle matters. A pupil who misses school because of anxiety can fall behind with work, lose contact with friends, and feel increasingly worried about what they have missed, which makes returning feel even more daunting.
A pupil who is increasingly anxious, reluctant to attend or beginning to avoid particular situations in school may need support before attendance becomes a persistent problem.
Breaking that cycle early, before absence becomes entrenched, can make a significant difference to academic outcomes.
The link between attendance and attainment is increasingly recognised in education policy. The government’s 2026 schools white paper, Every Child Achieving and Thriving, places attendance firmly alongside engagement, wellbeing and educational outcomes.
It sets an ambition to raise attendance to above 94% by the 2028–2029 academic year, while recognising that poor attendance can be both a symptom and a cause of disengagement.
Despite changes in government since Every Child Achieving and Thriving was published, the overall direction of travel remains the same. The Department for Education continues to publish and update material relating to the white paper, including SEND reform guidance released as recently as last month.
For schools, this reinforces an important point: attendance is not simply a number on the register, it can be a window into a child's wellbeing.
🎯 Medical Tracker can help staff spot patterns – such as repeated first‑aid visits for headaches or stomach aches – early, allowing your team to raise concerns before attendance begins to decline.
There is rarely a single explanation for school anxiety. The following are some of the most common contributing factors school staff may encounter. For some pupils, one particular difficulty may be significant. For others, several factors may overlap.
Social situations can feel particularly difficult for pupils experiencing social anxiety. They may worry about being judged, embarrassed or rejected. The NHS identifies fear of school, classroom activities and social events as possible signs of social anxiety in children. A pupil who avoids presentations, group work, assemblies or busy communal areas may therefore need more than a reminder to "join in".
📌 In 2023, over 36% of 11- to 16-year-olds with a probable mental disorder reported being bullied in person, compared with 7.6% of those unlikely to have a mental disorder. [NHS England]
This number highlights why peer relationships and a pupil's sense of safety should be considered when anxiety symptoms or attendance begins to change.
School staff should be aware that bullying is not always visible – a pupil may be reluctant to disclose what is happening, particularly if they fear that speaking up will make things worse.
Note: If you’d like to explore the Department for Education’s expectations around preventing and responding to bullying, you can read the latest guidance here.
Worries about schoolwork, assessments, exams, and falling behind can all contribute to anxiety. For some pupils, anxiety about attainment can become part of a wider cycle: worrying about work can make it harder to concentrate, falling behind can increase worry, and the prospect of returning to school can then feel even more difficult.
Encouraging attendance alone may not be enough — many pupils also need help with the underlying worries they have about their schoolwork.
For pupils living with long-term health conditions, school can involve additional considerations around symptoms, medication, appointments, fatigue, pain or managing their condition alongside learning – all of which can make school feel more demanding.
Physical and emotional wellbeing are closely connected.
📌 The 2025 OxWell Student Survey, which involved more than 35,000 pupils aged 9 to 18, examined mental health alongside physical health, chronic pain, school absence and other areas of wellbeing. Its findings highlight the importance of considering pupils' wider circumstances rather than looking at attendance or anxiety in isolation. [The OxWell 2025 Survey]
Pupils with additional needs may face particular barriers within the school environment; sensory, social, communication, or learning demands that are not always visible to staff.
📌 The 2025 OxWell Student Survey found that approximately one in five pupils self-identify as neurodivergent, and that neurodivergent pupils were more likely to experience persistent absence. [The OxWell 2025 Survey]
This does not mean neurodivergence causes Emotionally Based School Avoidance, but it does reinforce the importance of understanding the individual barriers a pupil may be experiencing within the school environment.
Feeling connected to school is more protective than it might seem.
📌 DfE research found a significant association between school belonging and attainment at Key Stage 4, with pupils who reported a stronger sense of belonging achieving higher GCSE results even after accounting for prior attainment and background factors. [DfE, 2025]
📌 In March 2026, 79% of both Key Stage 3 and Key Stage 4 pupils reported feeling they belonged at school every day or most days during the week surveyed. [DfE, 2026]
For the pupils who do not feel that sense of connection, building relationships with trusted adults and creating opportunities for belonging can be an important part of wider support.
💡 Good to know: A pupil's anxiety may not be caused by school itself. School can instead be the place where wider difficulties become more visible. Looking at the whole picture, including health, relationships, additional needs, home circumstances and the pupil's own perspective, can help staff understand what might be making attendance difficult and cause EBSA.
Anxiety does not always look like anxiety. It may present as physical symptoms, behavioural changes, or shifts in attendance, often long before a pupil is able to articulate what they are feeling.
Physical signs:
👉 Headaches
👉 Stomach aches or nausea
👉 Feeling dizzy or faint
👉 Tiredness or fatigue
👉 Rapid heartbeat or shaking
👉 Shortness of breath
👉 Frequent first-aid visits without an obvious physical explanation
Emotional and behavioural signs:
👉 Withdrawal or becoming unusually quiet
👉 Irritability or emotional outbursts
👉 Difficulty concentrating
👉 Increased reassurance-seeking from school staff
👉 Reluctance to enter classrooms or lingering in corridors
👉 Increasing lateness or avoidance of particular lessons
👉 Declining attendance
There is no single checklist, but staff and families may notice:
👉 Distress before school – particularly on Sunday evenings and Monday mornings
👉 Repeated requests to go home or stay at home
👉 Physical symptoms that ease once the pupil is away from school
👉 Difficulty separating from parents at the start of the day
👉 Withdrawal from friends or activities they used to enjoy
👉 Anxiety around particular lessons, teachers or locations within school
👉 Difficulty returning after an absence, however brief
👉 Changes in mood, behaviour or engagement over time
Often, it is the pattern that matters. A pupil who visits the first-aid repeatedly, always before the same lesson, always with the same complaint, may be experiencing EBSA.
🎯 With Medical Tracker’s CPOMS integration, relevant medical information can be shared with safeguarding records, helping pastoral and safeguarding teams see a fuller picture of a pupil’s wellbeing. Connecting health and safeguarding information can make it easier to spot patterns, understand concerns in context and take action when additional support may be needed.
School staff are not expected to diagnose anxiety or EBSA. Instead, the first response can focus on listening, being understanding, taking pupils' concerns and worries seriously, and involving the right people.
Helpful approaches include:
✅ Staying calm and giving the pupil time – anxiety responds poorly to pressure
✅ Using open, gentle questions, for example, "How are you feeling about today?"
✅ Taking physical symptoms seriously, even when no physical cause is found
✅ Looking for patterns across days, lessons and contexts
✅ Identifying trusted adults the pupil feels comfortable with
✅ Communicating early with parents – before attendance becomes a persistent issue
✅ Sharing concerns with pastoral, safeguarding, SEND or attendance colleagues
✅ Keeping clear, accurate records of presentations and actions taken
What to avoid:
❌ Dismissing symptoms as “just anxiety” or "attention seeking"
❌ Labelling a pupil as lazy, difficult or unmotivated
❌ Using shame, pressure or punitive attendance messaging
❌ Pressuring a pupil to explain feelings
❌ Pressuring a pupil to explain feelings they may not yet understand
❌ Assuming every absence is caused by ESBA – other factors may be at play
💡 Good to know: Avoidance provides short-term relief but tends to make returning harder over time. Understanding what sits behind the avoidance, rather than focusing solely on the absence itself, is what enables schools to provide the right support.
Parents and carers are essential partners in supporting pupils with school anxiety, and many will already be worried, exhausted, or unsure what to do. Early contact, a non-judgemental tone, and a collaborative approach will almost always produce better outcomes than a conversation framed around attendance figures.
Useful conversations with families might explore:
👉 When anxiety tends to appear, such as particular days, lessons, or times of year
👉 Physical symptoms the family has noticed at home, particularly before school
👉 What happens when the pupil stays at home — does anxiety ease quickly?
👉 Whether anything has changed recently at home or at school
👉 What has helped in the past, and what has not
👉 Whether the family has sought or is considering medical or therapeutic support
Families may already feel worried or overwhelmed. A supportive, non‑judgemental tone can make difficult conversations easier for everyone involved.
💡 Good to know: The DfE's guidance on mental health and attendance emphasises understanding the barriers a pupil faces and working collaboratively with families, rather than applying pressure or treating absence as a behaviour problem.
School staff are not expected to provide therapeutic or clinical support for anxiety or EBSA, but knowing when to escalate, and to whom, is important.
Consider involving additional support – including the SENCO, mental health lead, designated safeguarding lead, or an external referral – when:
The NHS advises seeking professional help where anxiety is severe, getting worse, or interfering with everyday life. GPs, CAMHS, and Early Help services are all potential referral routes depending on the pupil's level of need.
Supporting anxiety-related attendance difficulties cannot sit with one member of staff. A consistent, whole-school approach, where staff understand what anxiety looks like, where trusted adults are known and accessible, and where attendance is understood as a wellbeing indicator as much as a compliance measure, creates the conditions in which anxious pupils are more likely to stay connected, stay engaged, and ask for help.
A pupil saying "I can't go in" may be communicating something they do not yet have the words to explain. Listening to that message, rather than focusing solely on the absence, is often where the right support begins.
👉 Guidance for Parents – Understanding EBSA (tri-fold brochure)