How is this different from school counseling?

Cartwheel provides clinical mental health treatment from licensed therapists specializing in school avoidance, which differs from school counselors who focus on academic and social guidance. Our clinicians are specifically trained in evidence-based approaches for school refusal and anxiety disorders.

What is the difference between school avoidance and truancy?

School avoidance is driven by emotional distress such as anxiety, depression, or trauma, where students want to attend but struggle due to mental health barriers. Truancy typically involves willful absence without emotional distress as the primary cause.

How quickly can students access services?

Students can typically access services within 7-10 days of referral.

Does Cartwheel provide full-spectrum treatment?

Yes, Cartwheel provides comprehensive mental health care including individual therapy, parent guidance, psychiatric evaluations, and medication management when needed.

Is teletherapy effective for school avoidance?

Yes, teletherapy has proven effective for treating school avoidance. It provides accessible, convenient care that removes barriers to treatment and allows for flexible scheduling.

How are outcomes measured?

Outcomes are measured through validated clinical assessments, attendance data tracking, and the School Refusal Assessment Scale (SRAS) to monitor progress throughout treatment.

Is medication management available?

Yes, psychiatric evaluations and medication management are integrated into the program when clinically appropriate.

What is expected of families?

Families are expected to be committed to regular participation, seek guidance actively, and serve as active treatment partners in their child's care.

What is required of school staff?

School staff coordination involves collaboration with Cartwheel clinicians to support student progress and implement recommended accommodations.

Is the program compatible with IEP/504 plans?

Yes, the program is fully compatible with IEP and 504 plans and can support documentation and recommendations for educational accommodations.

Case Study: Salem Public Schools

Case Study: Salem Public Schools

Salem Students Receiving Cartwheel Services See 45% Drop in Chronic Absenteeism

45% reduction in chronically absent students receiving care from Cartwheel

50% reduction in unexcused absence rate

64% of students with prior out-of-school suspensions had none after Cartwheel

Measurable results for students and schools

As one of Cartwheel's first district partners, Salem Public Schools recognized that many students couldn't access the mental health support they needed. Rising chronic absenteeism and behavioral incidents signaled a growing need—but systemic barriers like long waitlists, transportation challenges, and scheduling conflicts were keeping students from getting timely care.

Salem needed a partner who could expand access quickly, deliver high-quality care, integrate seamlessly with school teams, and provide data to demonstrate impact. Over four years of partnership, Cartwheel has delivered.

Download Case Study

Salem, Massachusetts

3,800 students across
11 schools

60% low income

Sample size: n=334 students who were referred to Cartwheel telehealth services in a 3,800 student suburban district (60% low income) during the 2022-23, 2023-24, and 2024-25 school years.The first bar shows the number of students who were chronically absent in the school year prior to receiving services. For the same cohort, the second bar shows the number who were chronically absent in at least one subsequent school year. For this analysis, we have data on at least one subsequent year for all students (the most recent cohort has data for one year post, while earlier cohorts have data for 2 or 3 subsequent years). Chronic absenteeism is defined as missing 10 percent of school days within an academic year.

Absences per Student Before vs. After Cartwheel

↓ 45%

Reduction in number of chronically absent students

↓ 50%

Reduction in  unexcused  absence rate

↓ 64%

Of students with prior out-of-school suspensions had none after Cartwheel

Clinical outcomes that support academic success

66%

Students

who completed care or are 90+ days in care achieved clinically significant symptom reduction

~5,500

Sessions

delivered since the start of our partnership

92%

Students

enjoy meeting with their therapist

87%

Students

find it helpful to meet with their therapist

“Chronic absenteeism isn't just an attendance problem—it's often a mental health problem. Before Cartwheel, we were seeing the consequences of untreated mental health needs play out in our attendance data. Cartwheel helped us address those root causes—and the 45% reduction in chronically absent students shows what's possible when mental health support is accessible and integrated with schools."

Ellen Wingard

Executive Director of Student Support Services
Salem Public Schools

What This Meant for Salem Public Schools

More Instructional
Time

Additional school days means better academic outcomes and improved accountability metrics

Improved School
Climate

Fewer behavioral incidents means less disruption for all students

Better Resource
Allocation

School counselors can focus on tier 1 and tier 2 supports instead of crisis management

Stronger Family
Engagement

Parents receive guidance that improves outcomes at home and school

Student Success Story

Dani* had been struggling with school avoidance, peer relationships, and conflict. The year she was referred to Cartwheel, she had 31 absences (27 unexcused).

After completing a teletherapy program with Cartwheel, Dani's attendance improved by 32% with 21 absences (1 unexcused) the following year.

Referral
School counselor talked to Dani and mom and submitted a referral to Cartwheel

Intake
A therapist held a 1 hour intake with Dani, drafted a care plan, and sent an update to the counselor. Mom shared she did not know how to address Dani's chronic absenteeism and anxiety management.

Personalized Care
Dani started 1-1 weekly therapy sessions focused on building skills to improve mood at school and improve her ability to consistently attend school. Dani's mom also met 1-1 with the same therapist to work on strategies to support Dani. After a couple of months, Dani also began medication management through Cartwheel.

Ongoing Support
After 1 year of individual therapy, parent guidance, and psychiatry sessions, Dani's mental health improved significantly and she graduated from the Cartwheel program. Dani's attendance rate improved 32% compared to the prior year.

* Student name has been changed to preserve anonymity

Why Salem Needed a Different Approach

Like districts nationwide, Salem recognized growing student mental health needs— and the barriers families faced accessing care.

Before Cartwheel, students needing tier 2 and tier 3 support faced:

3-6 month waitlists for other providers

Transportation challenges preventing families from attending appointments

Language barriers limiting access for  non-English speaking families

Overwhelmed school staff managing increasing crises with limited resources

The consequences appeared in the data: rising chronic absenteeism and increasing behavioral incidents. Students struggling with untreated anxiety, depression, and trauma were missing school, acting out, and falling behind academically. These barriers didn’t just impact well-being—they eroded instructional time and academic progress district wide.

School Avoidance Program

Students with Mental Health Needs Miss Twice as Many Days of School

Cartwheel's specialized School Avoidance Program helps students address the challenges at the root of chronic absenteeism—so they can confidently return to school.

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What Makes Cartwheel Different

Salem Public Schools partnered with Cartwheel to remove barriers, integrate with school teams, and address the root causes of attendance and behavior challenges.

Specialized for school outcomes

Therapy, psychiatry, and family support focused on school avoidance, anxiety, depression, and behavioral challenges.

Rapid access to care

Students are matched with clinicians in 7–10 days instead of waiting months.

Integrated with school teams

Ongoing collaboration with counselors and social workers, shared strategies, and real-time progress updates.

Sustainable through insurance

No costs for families on Medicaid; in-network with military and commercial insurers.

Multilingual care

Students are matched with a clinician who speaks their native language.

Salem Students Receiving Cartwheel Services See 45% Drop in Chronic Absenteeism

Absences per Student Before vs. After Cartwheel