Too many missed school days? Policy says ask about chronic absenteeism
Mandy A.Allison, M.D., M.S.P.H., M.Ed., FAAP
E.J., an 11-year-old patient, comes to clinic with his mother for headaches that come
and go throughout the day. You ask how many school absences E.J. has had in the past
month and learn he has missed eight days due to headaches and also was suspended for
fighting and has been bullied at school. You rule out serious underlying conditions
as the cause for the headaches. Then, you empower the mother to meet with the school
principal or counselor to establish a plan to address the bullying.
The new AAP policy statement The Link Between School Attendance and Good Health suggests that pediatricians ask about the number of missed school days in the past
month at every visit for school-aged children, when appropriate, because the question
can yield a wealth of information to optimize patient care. The policy, from the Council
on School Health, is available at https://doi.org/10.1542/peds.2018-3648 and will be published in the February issue of Pediatrics.
Definition, effects of chronic absenteeism
Chronic absenteeism often is defined as missing 10% (around 18 days) of the entire
school year for any reason, including excused and unexcused absences and suspensions.
Chronic absenteeism is different than truancy, which usually refers to when a student
willfully misses school, and the absence is “unexcused.”
Although students who are truant may be chronically absent, focusing solely on truancy
may overlook students who miss excessive amounts of school for excused reasons.
Regardless of whether absences are unexcused or excused, chronic absenteeism puts
students at risk for poor school performance and school dropout. As a result, they
are at risk for unhealthy behaviors as adolescents and young adults as well as poor
long-term health outcomes.
Multiple factors involved
Students miss school for a variety of reasons, including illness, feeling unsafe at
school, family responsibilities such as having to watch a younger sibling or care
for an ill adult, housing instability, transportation difficulties, not seeing the
value in attending school, lacking a responsible adult to require school attendance,
and not realizing that missing school can be a problem because absences can add up
Significant disparities in chronic absenteeism exist based on income, race and ethnicity.
Pediatricians have opportunities at the patient, practice and population levels to
promote school attendance and reduce chronic absenteeism and resulting disparities.
The policy describes evidence for physical and mental health interventions to improve
school attendance. It also provides recommendations for how pediatricians can address
school attendance in their practices, communities, states or nationally as advocates
using a tiered approach.
Pediatricians can promote school attendance for all youths as follows:
Ask about school attendance (number of missed school days in the past month) at every
visit, when appropriate.
Promote school attendance by using materials such as handouts, posters or videos in
the office; communicating via the practice website or social media; and praising patients
and caregivers when patients are attending school regularly.
Provide firm guidance on when a child should stay home if sick, when to return to
school and how to avoid absences due to minor illness or anxiety.
Recommendations to improve school attendance for patients who are missing two or three
days of school per month (about 10% of total school time) or more include the following:
Prevent, identify and treat physical and mental health conditions that are contributing
to school absences.
Avoid writing excuses when the absence was not appropriate and avoid backdating to
Avoid contributing to school absences by offering extended office hours, encouraging
families to make preventive care and follow-up appointments outside of regular school
hours, and strongly encouraging patients to return to school immediately after their
medical appointments if they are well enough.
Dr. Allison, a lead author of the policy statement, is a former member of the AAP
Council on School Health Executive Committee.