Adjusting to Primary School

Children whose school refusal had lasted less than a year were found to be 3.28 times more likely to return to school.

This finding comes from a retrospective cohort of 235 psychiatric patients under the age of 15 who were followed for one year (Sasaki et al., 2026). It does not, on its own, establish causality. But the direction is clear: the longer children stay away from school, the harder it becomes to return.

Abdominal pain during the first few weeks is often not about the stomach. In a study of 128 children diagnosed with an anxiety disorder, the most common physical symptoms were restlessness (74%) and abdominal pain (70%). The pain is real. Its source lies elsewhere.

The good news is this: in a cohort that followed 1,933 families, symptoms decreased substantially by around age 6 in most children who showed high levels of separation anxiety early in life. The group whose symptoms remained high represented only 6.9% of the sample.

Five practices with the strongest evidence

1. Do not reinforce avoidance. When families adjust their behavior to accommodate a child's anxiety, this is known in the literature as family accommodation, and it is most strongly associated with separation anxiety. In a randomized trial involving 124 children, working only with the family produced outcomes no worse than therapy with the child.
2. Do not prolong school absence. Avoiding school brings short-term relief but makes things harder in the long term.
3. Protect sleep and maintain a consistent bedtime. In a randomized trial involving 34 children, emotional lability scores improved in children whose sleep was extended by an average of 27 minutes and worsened in those whose sleep was restricted by 54 minutes. In a cohort of 10,230 children, switching to a regular bedtime improved behavioral scores.
4. Make sure there is a familiar face in the classroom. Children with a higher proportion of familiar peers had more positive attitudes toward school and were observed to be less anxious at the start of the school year.
5. Strengthen the relationship with the teacher. In a study of 517 first-grade students in Ankara, the two variables that directly predicted school adjustment were relationships with teachers and relationships with peers.

If symptoms persist for weeks and interfere with the child's daily functioning, an assessment is needed. In a meta-analysis involving 2,656 children with a mean age of 5.45 years, cognitive behavioral interventions reduced anxiety more than control conditions.

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