Michelle Shankar, MD, discusses health-related school absenteeism in children

Children with chronic health conditions and health-related social needs were more likely to experience elevated health-related school absenteeism, according to findings from a nationally representative study published in JAMA Pediatrics.¹

Investigators analyzed data from 66,752 children aged 6 to 17 years included in the 2022-2023 National Survey of Children’s Health, representing an estimated 49.3 million US children. Elevated health-related school absenteeism was defined as missing 11 or more school days due to illness or injury during the prior year.²

The prevalence of elevated health-related school absenteeism in the study population was 6.8%, representing approximately 3.4 million children nationwide. Children with both chronic health needs and health-related social needs had the highest estimated probability of elevated absenteeism at 9.4%, compared with 1.8% among children without either type of need.

Michelle Shankar, MD, MHS, a general pediatrician and clinician researcher at Children’s Hospital at Montefiore and lead author of the study, said school attendance may offer pediatricians another way to assess a child’s overall functioning.

“As pediatricians, we often focus on the patient in the exam room, we look at their growth chart, we review their vital signs, we ask about symptoms of any illnesses that they might have, but what those questions don't totally capture is that how that child's health impacts their ability to function in their day-to-day life, and a key indicator of that is their ability to be present and engaged in school,” Shankar said. “So our study looks at how school attendance might help us to understand a child's overall function and well-being across health and academic domains.”

Which mental health conditions were linked to absenteeism?

Mental and behavioral health conditions were among the strongest factors associated with absenteeism. Children with anxiety had an adjusted odds ratio (aOR) of 3.22 for elevated absenteeism, while children with depression had an aOR of 3.83 compared with peers without those conditions.

“Our study showed that children with anxiety and depression were more than three times as likely as their peers, to have health-related school absenteeism,” Shankar said. “This could be due to a variety of factors. This could be school refusal, poor engagement in the school setting, or behavioral concerns resulting in things like out-of-school suspensions, all of which lead to missed instructional time.”

She added that attendance problems may provide an early signal of unmet mental or behavioral health needs.

“Our study starts to suggest that school attendance may be the first signal to a child's family, school, or healthcare provider that there's an underlying mental or behavioral health need, and given the sharp increases in youth mental health needs since 2020, I think this is something that we should start paying attention to,” Shankar said.

How do social determinants of health affect school attendance?

The study also identified significant associations between absenteeism and household social needs. Children experiencing housing instability or food insecurity had estimated absenteeism probabilities above 10%, and absenteeism risk increased with greater exposure to adverse childhood experiences.

“Compared to children who don't have any chronic health or social needs, children who had any household-related social needs, housing instability, food insecurity, they were twice as likely to have elevated health-related absenteeism, and kids with health and social needs combined were more than five times as likely,” Shankar said.

Shankar said screening for social determinants of health may help pediatric practices identify children at risk.

“The first step is screening for those needs in clinical settings and having systems in place for patients who disclose those needs,” she said. “Here at the Children's Hospital at Montefiore, we have a universal social determinants of health screener that all patients receive, and those with positive screens are referred to community health workers who can connect families to resources and follow up with them until those needs are met.”

Can school attendance become a pediatric vital sign?

The investigators concluded that chronic absenteeism should be viewed not only as an educational issue, but also as a public health concern requiring collaboration between healthcare and school systems.

Shankar said pediatricians can begin by routinely asking families about missed school days during visits.

“My dream is for a pediatrician to be able to open a child's chart and look at their growth curve, see how they're growing, look at their blood pressure, and look at their school attendance as vital signs of their overall health and well-being,” she said. “Until we have the infrastructure for that, simply asking families about their school attendance can be a meaningful place to start.”

References

1. Shankar M, Levano SR, Lemberg M, et al. Health-related school absenteeism among US school-age children with chronic health and social needs. JAMA Pediatr. Published online April 27, 2026. doi:10.1001/jamapediatrics.2026.1138

2. US Department of Education. Chronic absenteeism. Accessed May 19, 2026. https://www.ed.gov/teaching-and-administration/supporting-students/chronic-absenteeism