Intensive interventions for emotionally based school avoidance: a scoping review of program structures and therapeutic levers.

BACKGROUND: A substantial proportion of children and adolescents with emotionally based school avoidance (EBSA) do not benefit from outpatient mental health interventions. In such instances, more intensive interventions may be warranted. There is a lack of synthesised knowledge, however, to guide professionals and families about what intensive interventions comprise, how they generate change, and when they are indicated. OBJECTIVE: To map and synthesise the literature on intensive interventions for EBSA, in terms of target populations, intervention structure and delivery, therapeutic levers, implementation challenges, and reporting completeness. METHODS: A systematic search of five databases and grey literature sources (2000-2026) identified 1,581 records. Following screening and full-text review, 19 publications describing 17 samples across 13 programs met inclusion criteria. Data were charted using a structured coding manual informed by TIDieR, the Medical Research Council framework for complex interventions, and STROBE reporting guidelines. Numerical summaries were combined with narrative synthesis to describe patterns in sample characteristics, intervention structure, therapeutic levers, implementation challenges, and reporting completeness. FINDINGS: Intensive interventions commonly targeted adolescents with severe, often chronic, school non-attendance and substantial psychiatric comorbidity. Four program types were identified: outpatient, alternative education, day hospital, and inpatient. The latter three types utilised a transitional setting staffed by a multidisciplinary team to deliver integrated health and education support. High-intensity graded exposure, educational scaffolding, therapeutic peer milieu, health-education systems coordination, and the transitional space were key therapeutic levers for facilitating engagement and eventual return to school. Common implementation challenges included sustaining engagement, managing progression through treatment, and resource constraints. Whilst the reported outcomes were promising, inconsistent reporting limited inferences about the indications for intensive interventions. CONCLUSIONS: Intensive EBSA interventions are best understood as programs that restructure the conditions of care to enable implementation of evidence-based treatments. This review identified a typology of intensive intervention models and recurring therapeutic levers, providing a foundation for future research. Improved specification of the target population and intervention models, together with investigation of the mechanisms of change, will help clarify their role within multi-tiered intervention frameworks for EBSA.