About Sagal
I am an ACP-registered Child and Adolescent Psychotherapist with more than a decade of experience across NHS CAMHS, paediatric services and schools. My experience includes supporting children and young people across school, nursery, SEND and specialist SEMH settings.
My work has included therapeutic intervention within education, contributing to EHCPs, supporting parents, working alongside school staff, and bringing a child-psychotherapy perspective to neurodevelopmental assessment. At the Gloucester House Day Unit, a specialist SEMH provision, I worked with children experiencing complex emotional, behavioural, developmental and learning needs, including trauma and significant difficulties engaging with education.
This experience shapes how I understand Emotionally Based School Avoidance. I do not view school avoidance simply as an attendance problem, but as a sign that something about school, or the demands surrounding it, has become too difficult to manage. This may involve anxiety, neurodivergence, sensory overwhelm, demand avoidance, academic pressure, bullying, friendship difficulties, low mood or physical symptoms.
I work with children, adolescents and parents to understand what is driving the distress and what may help. My approach is psychodynamic, developmentally informed and neurodivergence-sensitive, with attention to the child’s emotional world as well as the sensory, social, academic and relational environment around them.
Where helpful, I can also support parents in thinking about communication with school and the wider professional network, while keeping the young person’s experience at the centre of the work.
What school attendance difficulty can look like
Your child may:
become distressed on Sunday evenings, school mornings or the first day back after a break;
report headaches, stomach aches, nausea, dizziness, exhaustion or panic before school;
struggle to wake, dress, eat, leave the house or cross the school threshold;
attend intermittently, arrive late, leave early or remain in one safe room;
mask through the school day and collapse, shut down or become explosive at home;
retreat to their bedroom, screens or a reversed sleep pattern;
fear particular lessons, teachers, peers, corridors, assemblies, lunchtimes or transitions;
become preoccupied with missed work, falling behind or how others will react to their return;
appear relieved when allowed to stay home, then increasingly anxious as absence continues;
say they do not know why they cannot go.
None of these signs proves one explanation. They show that the child’s capacity, sense of safety or relationship with school needs closer attention.
What may be happening beneath the absence
School has become associated with threat
The threat may be obvious, such as bullying, humiliation or an unsafe peer situation. It may also be cumulative: repeated correction, feeling watched, public mistakes, unpredictable transitions, sensory pain or the experience of never quite understanding what is expected.
Coping has become unsustainable
Some children maintain attendance through intense effort, masking or compliance until the cost can no longer be paid. The collapse may look sudden to adults even though the strain has been accumulating for months or years.
The body has become part of the alarm system
Pain, fatigue, nausea, headaches, dizziness and other symptoms may be medically explained, functional, stress-sensitive or still under investigation. They should not be dismissed as an excuse. The relevant question is how physical and emotional experience are interacting and which service needs to lead.
Achievement or belonging feels at risk
A child may be unable to enter school because a mistake, imperfect result, changed friendship or visible struggle feels unbearable. Avoidance can protect them temporarily from shame while making the eventual return feel more exposing.
Home has become the only place recovery seems possible
Staying home may bring immediate relief from demands, scrutiny or exhaustion. That relief is real. Over time, however, life may narrow: sleep shifts, friendships weaken, confidence falls and the imagined return becomes larger. This does not mean home caused the problem; it means the cycle now needs a thoughtful response.
How the cycle can reinforce itself
Distress makes attendance harder. Missing school then creates new pressures: missed learning, unanswered messages, changing friendships, adult concern and fear about what returning will involve. The child may need more certainty before returning, while the school needs attendance in order to understand what helps. Parents become caught between protecting a distressed child and fearing that every day at home makes the future harder.
There is no single intervention that reliably resolves school absence for every child. Effective support usually depends on understanding the individual barriers, working with the family and school, and changing what the child is being asked to return to—not simply increasing pressure at the front door.
How I work with school attendance difficulties
I use a low-demand, psychodynamic approach. I do not begin by asking the child to defend their absence or set a return date. We first need to understand what school has come to represent, what happens in the body and mind as attendance approaches, what the child is protecting themselves from and which demands or relationships require change.
The work may include:
parent counselling if your child is not ready to go into therapy yet.
a three-session assessment that lets the young person experience the setting without promising treatment;
individual psychotherapy through conversation, play, drawing, sensory materials, games, movement or silence;
parent appointments to think about morning conflict, reassurance, boundaries, accommodation and recovery;
focused liaison with school, the SENCO, GP, paediatrician or another clinician where agreed and clinically useful;
a home visit considered separately where severe or long-standing non-attendance makes leaving home an immediate barrier;
termly review of wellbeing, agency, relationships, engagement and educational participation without using attendance alone as proof of recovery.
Psychotherapy does not replace the school’s responsibility to understand barriers, provide suitable support, make reasonable adjustments where applicable and respond to safeguarding or bullying concerns. In my work, it has become clear that reasonable adjustments and changes to the educational environment can only achieve so much.
The work begins by making the pattern more understandable. Attendance matters, but pressure to produce attendance before the child and the environment can sustain it may deepen fear, conflict and collapse.
We take it step by step: not every young person needs psychotherapy
→ You are here
1. Getting advice / signposting
Parent Consultation
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2. Getting the right support
Psychotherapy Assessment · 3 sessions
Three sessions for your child to try therapy with me. These may be enough, or we may agree on weekly psychotherapy, different support or another service. There is no commitment to long-term treatment.
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3. Getting more support
We agree the plan together: weekly psychotherapy during term time, with parent counselling, school liaison or other support where useful. Additional work is agreed in advance and billed at £360 per hour, pro rata.
A pathway that begins before the child is ready for therapy
The pathway is organised around current need and choice rather than an escalator of severity. A Parent Consultation may be enough to help adults change the response. Assessment may clarify that school or medical input should lead. Weekly psychotherapy is considered only when the young person can use it and it adds something distinct.
I take a low-demand approach, avoiding making therapy another task for a child already struggling with school and everyday expectations. At each stage, I pay attention to whether the young person feels able and willing to continue. Giving them a genuine say helps trust develop and makes practical work towards education more possible.
I keep a deliberately small caseload so I can remain consistent and adaptable. Where school non-attendance is severe or long-standing, home visits can be discussed and may offer a more workable beginning than online sessions.
40 minutes · Online · Parents only
Parents often book when mornings have become a repeated crisis and every response feels wrong: insistence escalates distress, flexibility seems to confirm avoidance, and communication with school has become strained.
Your child does not attend. We think about when attendance changed, what school now represents, and what happens before and after absence. My aim is to help you develop an initial understanding of the difficulties, consider how to respond at home and decide what to discuss with school, your GP or another professional. You receive a one-page A4 recommendations letter.
The consultation can stand alone. School support, medical assessment or another service may be the most useful next step. Any later assessment or psychotherapy with me is considered separately, subject to clinical fit and availability. A diagnostic assessment, formal report and professional liaison are not included in this appointment.
i-THRIVE lens: Getting Advice and Signposting.
Three 50-minute appointments; parent(s) join the first
Across three appointments, I consider more than whether your child can attend the room. We notice how they manage separation, uncertainty, demands, being observed and accepting help, while exploring school, relationships, health, sensory experience, neurodivergence and the history of the attendance difficulty. Parent feedback brings this into an initial psychotherapeutic formulation and recommendations. Assessment may lead to weekly work, changes around school or home, another service or no further treatment with me.
i-THRIVE lens: shared decision-making and clarification of current need.
Weekly psychotherapy during term time
A regular 50-minute appointment gives your child space to explore fear, shame, exhaustion, anger and their experience of school. We agree together the scope of parent work, school liaison and other clinical activities in advance. You have a say in the plan. Additional work is agreed and billed separately.
Progress is considered through recovery, relationships, engagement and a sustainable relationship with education. See Fees for session prices and billing arrangements.
i-THRIVE lens: Getting Help or Getting More Help, according to the support needed.
Related difficulties
School attendance difficulties rarely occur alone. They can be affected by several different issues. My approach is about working across all aspects of your child’s life, in order to facilitate development and change holistically.
What progress may look like
Progress might include:
For parents and family: less fear or conflict when discussing school, and more thoughtful, flexible expectations.
For the young person: more reliable recovery after educational or social demands; finding their voice; greater awareness of their limits and strengths; renewed interest in learning and hobbies; and better-quality friendships.
For everyone: a clearer shared account of the barriers to attendance and a more joined-up response.
For school: personalised adjustments that address the barriers, gradual and sustainable attendance goals where possible, and an environment in which the young person can ask for help.
Over time, the young person may recover more readily from setbacks and see attendance and emotional wellbeing as more than a question of success or failure.
Frequently asked questions
EBSA describes attendance difficulty associated with emotional distress. “School refusal” can sound as though the child is making a simple oppositional choice. Some children do refuse, but the clinically useful question is what makes attendance feel unsafe, impossible or too costly and what conditions maintain that response.
There is no universal answer. Repeated coercion can intensify panic, rupture trust or produce attendance that ends in collapse. Removing every expectation indefinitely can also allow life to narrow. The response needs to match the child’s capacity, the reason for the distress and the school’s ability to make attendance safer and more sustainable.
Describe observable distress, patterns, physical symptoms, known vulnerabilities and what happens before and after attendance. Ask the school to identify barriers with you rather than relying only on sanctions or exhortation. The current attendance framework expects schools and local authorities to work with families and provide support for pupils who are persistently or severely absent.
Parents can begin with the online consultation. Where direct assessment is appropriate, the location and pace are considered individually. A home visit can sometimes be discussed when leaving home is a major barrier, but it is not automatic and does not guarantee ongoing home-based psychotherapy.
I can contribute a psychological formulation and focused recommendations where this is clinically useful, consented and within the agreed work. The school remains responsible for deciding and implementing educational support, reasonable adjustments, attendance planning and safeguarding. Liaison is considered where clinically appropriate and agreed within the work; it is not included automatically in a Parent Consultation.
Psychotherapy can help a child or teenager understand what makes school feel unsafe or impossible and can support parents in thinking about practical, emotional and school-based support.
We agree together how parent meetings could support your child. They may be regular or arranged when needed, depending on the treatment plan. They give us space to think about school mornings, recovery, family responses and changes around education while protecting your child’s private therapeutic space, subject to safeguarding responsibilities. You have a say in the frequency and scope. Parent work is billed separately at £360 per hour, pro rata.
A Parent Consultation can still be a useful first step when a child is not ready to attend therapy. Psychotherapy asks something of the young person, and their own willingness matters. Assessment gives them time to experience the work and decide whether there is something they want to use it for. They do not need to arrive able to explain everything or already certain about continuing. The consultation can also consider whether parent work, reasonable adjustments or another service would be more useful.
Attendance difficulty can overlap with friendship difficulties, social anxiety, bullying, broader anxiety, exam pressure, neurodivergent burnout, pain or fatigue. The aim is not to make EBSA explain everything. The related pages below show which concern should lead when it is more central, and the Parent Consultation can help clarify an appropriate next step.
You can begin with a Parent Consultation to think about what has changed around school, what makes attendance difficult and what support is already in place. The next step may be parent work, Psychotherapy Assessment, changes around school, liaison with another professional or support from a different service. The consultation can stand alone; the recommendation depends on your child’s situation, consent, clinical fit and available capacity.
EBSA stands for emotionally based school avoidance; EBSNA stands for emotionally based school non-attendance. Schools and services use these overlapping terms for difficulties attending or accessing education where emotional distress, anxiety or overwhelm is involved. The difficulty may concern particular lessons, getting into school, staying for the day or more sustained absence. School anxiety is the broader experience of worry or distress connected with school. A child may still attend while finding it very difficult. These terms describe a difficulty rather than explain its cause: school experiences, relationships, learning needs, sensory demands, health and family circumstances may all matter. I consider the individual child and their context, rather than assuming that every attendance difficulty has the same explanation.
A young person who struggles to attend school may not know why. This can be a cause of frustration for parents and school, who struggle to put the right support in place as a result. Much of the time, the reason may be genuinely unknown to the child. Through the process of therapy, we figure out what might be going on underneath the surface. This could be a fear of failure, bullying, social anxiety or even boredom. Some children can struggle because their learning style or needs are different, but due to their attainment being OK, no flags are raised and they are not seen as struggling externally, when they are internally. Other children are highly intelligent in a way that is not obviously clear or traditional, and so they may not be challenged enough in an academic setting, which is where boredom creeps in.
Your child may not yet know why, or may struggle to put the experience into words. I do not begin by asking them to defend their absence or produce a complete explanation. We can explore what school has come to mean through conversation, play, drawing or other ways of communicating, while parents and school consider what is happening around them.
Behaviour alone does not establish one explanation. The useful question is what makes attendance feel unsafe, impossible or too costly for this child and what maintains that response. I consider the child’s capacity, sense of safety and relationship with school alongside what parents and school observe. A Parent Consultation can help us think about the pattern before deciding how to respond.
It can be useful when it is purposeful, reviewed and connected to the barriers the child is facing. It can become unhelpful when it simply postpones the same unsustainable demands or leaves the child isolated without a plan. The important questions are what the reduction is intended to achieve, how progress will be judged and what needs to change before hours increase.
No. Attendance is part of the context, not a prerequisite for emotional work. Therapy may help the child understand fear, exhaustion, shame or relationships while parents and school address practical barriers. A return may emerge gradually, take another form or remain limited while health and capacity recover.
There is no reliable standard timeline. The history, level of exhaustion, physical health, neurodivergence, school response, social safety and length of absence all matter. A quick return is not necessarily a stable one. Reviews focus on whether life is becoming more workable and whether the current plan remains useful.
Then attendance cannot be treated as an isolated anxiety problem. Sensory load, executive demands, masking, pain, fatigue, medical uncertainty and the need for recovery may all alter what is realistic. Assessment considers the whole pattern and whether another service or adaptation should lead.
Those changes require broader and potentially urgent assessment. Contact the relevant CAMHS, GP, NHS 111 mental health option or emergency service according to urgency, and use the school’s safeguarding route where relevant. Private weekly psychotherapy should not be the sole response when risk management is the primary need.
When another service should lead
This is planned outpatient psychotherapy, not an emergency, crisis, attendance-enforcement or diagnostic service. Sudden deterioration, serious self-harm, substance-related risk, severe restriction of eating, psychosis, inability to maintain safety or an urgent medical concern requires appropriate NHS or specialist assessment.
Active bullying and safeguarding concerns require direct action by the school or relevant statutory service. New or worsening physical symptoms require medical review. Where managing risk is the primary task, CAMHS or local crisis services must lead; this practice does not provide i-THRIVE Getting Risk Support.
When urgent or risk-led help is needed
This is a planned outpatient psychotherapy practice, not an emergency, crisis or risk-management service. Call 999 or go to A&E when someone’s life is at risk, there has been a serious injury or overdose, or you do not feel able to keep someone safe. For urgent mental-health help without immediate danger, call NHS 111 and select the mental health option, or ask for an urgent GP appointment. Concerns that a child may be at risk of abuse or serious harm should also be reported through the relevant safeguarding route.
Related pages
Autism, ADHD, masking and burnout — when attendance fell after prolonged effort, sensory overload or post-school collapse.
Bullying, friendships and social anxiety — when school no longer feels socially safe.
Functional symptoms, chronic illness, pain and fatigue — when health and physical capacity are central to absence.
Professional liaison — when focused communication with school, a GP or another service has a clear clinical purpose.
Psychological therapy for EOTAS — specialist psychotherapy for young people receiving or exploring Education Otherwise Than at School, including self-funded support.
Highgate practice — for in-person assessment or psychotherapy in North London.
Evidence and guidance for this page
Department for Education. Mental health issues affecting a pupil’s attendance: guidance for schools.
School absenteeism in autistic children and adolescents: a scoping review.
THRIVE Framework for system change: needs-led care, partnership and shared decision-making.
Devon County Council. Understanding emotionally based school avoidance (EBSA).
Warwickshire County Council. Emotionally based school non-attendance (EBSNA).
Written and clinically reviewed by Sagal Hassan, ACP-registered Child and Adolescent Psychotherapist. Last reviewed 31 August 2026.
Parent Consultation
40 minutes · Online · Parents only
A focused appointment to think about your child’s school difficulties and the next step. Your child does not attend. Includes a one-page A4 recommendations letter, with no obligation to continue into assessment or psychotherapy.