Is Bullying Associated with Emerging School Refusal in Autistic Boys?

Brief Report: School Anxiety, School Attendance and School Refusal/Distress Following an Autism-Specific Parent-Mediated Intervention for Anxiety in Preschoolers

PURPOSE

Autistic children have an increased likelihood of experiencing anxiety, even in the preschool years. Studies evaluating anxiety interventions in autistic children have tended to focus upon home or community settings. This study expands upon previous work to evaluate whether a parent-mediated intervention for autistic preschool children's anxiety impacts later school anxiety and school attendance.

METHOD

Data for this study comes from a randomised controlled trial of an autism-specific program designed to reduce and/or prevent anxiety in autistic preschoolers; CLK-CUES. In addition to pre- and post-group anxiety measures, the trial included data from parents and teachers one year later, once the children started school. Teacher-reported school anxiety and parent-reported school attendance data were available for the CLK-CUES (n = 15) and control group (n = 13).

FINDINGS

Children whose parents received CLK-CUES had lower levels of separation anxiety in school and significantly lower non-attendance rates than the control group. This was predominantly due to a significant between-group difference in the number of days missed due to school refusal/distress.

INTERPRETATION

Findings indicate promise for this autism-specific anxiety program to reduce school anxiety and support school attendance in young autistic children. Further research with larger samples and an extended follow-up is warranted.

Self-perceived bullying victimization in pre-adolescents on the autism spectrum: EPINED study

LAY ABSTRACT

Autistic individuals face a higher risk of various forms of victimization throughout their lives, with bullying being especially prevalent during their school years. Previous studies indicate that autistic children are 2.4 times more likely to be bullied than their typically developing peers and twice as vulnerable as those with other disabilities. However, the extent of this issue among Spanish schoolchildren with autism remains unexplored. In addition, there is no information regarding the presence of bullying victimization in children with marked but undiagnosed autistic traits (i.e. subthreshold autistic traits). This study examines the self-reported prevalence of bullying victimization in autistic pre-adolescents and those with subthreshold autistic traits, comparing them with peers without neurodevelopmental conditions. The study involved 323 participants (11 and 12 years old; 45 with autism or subthreshold autistic traits) from Spanish general education schools. The results revealed a higher rate of bullying victimization among autistic participants (58%; 3.1 times higher risk) and those with subthreshold autistic traits (27%; 1.5 times higher risk) compared with their peers without neurodevelopmental conditions (18.3%). Victimization was linked to more intense restrictive behaviours and increased behavioural and emotional problems. No significant associations were found with other individual or family factors. Our findings underscore the heightened risk of bullying faced by autistic pre-adolescents and those with subthreshold autistic traits at school, emphasizing the need to identify and implement preventive measures to mitigate bullying and its detrimental impact on their mental well-being and overall quality of life.

Neurological Validation of ASD Diagnostic Criteria Using Frontal Alpha and Theta Asymmetry

Background/Objectives: Diagnosis of Autism Spectrum Disorder (ASD) relies on the observation of difficulties in social communication and interaction, plus the presence of repetitive and restrictive behaviors. The identification of neurological correlates of these symptoms remains a high priority for clinical research, and has the potential to increase the validity of diagnosis of ASD as well as provide greater understanding of how the autistic brain functions. This study focused on two neurological phenomena that have been previously associated with psychiatric disorders (alpha- and theta-wave asymmetry across the frontal region of the brain), and tested for their association with the major diagnostic criteria for ASD. Methods: A total of 41 male autistic youth underwent assessment with the Autism Diagnostic Observation Schedule (ADOS-2) and 3 min of eyes-closed resting EEG to collect alpha- and theta-wave data from right and left frontal brain sites. Results: Different associations were found for theta versus alpha asymmetry and the ADOS-2 subscales, across different brain regions responsible for a varying range of cognitive functions. In general, theta asymmetry was associated with conversation with others, sharing of enjoyment, and making social overtures, whereas alpha asymmetry was linked with making eye contact, reporting events to others, and engaging in reciprocal social communication. Specific brain regions involved are identified, as well as implications for clinical practice. Conclusions: Specific autism symptoms may be associated with selected brain region activity, providing a neurological basis for diagnosis and treatment.

Bullying Victimization in Children and Adolescents and Its Impact on Academic Outcomes

ABSTRACT

Bullying victimization has been identified as a significant factor influencing academic outcomes. We sought to evaluate the educational outcomes and psychiatric comorbidities in children and adolescents who are victims of bullying using the National Survey of Children's Health dataset for the study. The participants were children and adolescents (age: 6-17 years) categorized into two groups: group 1, not bullied ( n = 21,015), and group 2, bullied more than once ( n = 21,775). Individuals whose health status was fair or poor have experienced more bullying (2.4% vs . 1.4%, p < 0.001). Individuals in the group 2 were more likely to repeat the grades than the group 1 (7.1% vs . 5.9%, p = 0.039). Individuals who were missing ≥11 school days and sometimes or never engaged in school were observed to be more in the group 2 compared with the group 1 (5.9% vs . 3.2% and 20.3% vs . 10.6%, p < 0.001). In conclusion, bullying victimization could be a risk factor and associated with decreased academic outcomes.

School absenteeism in autistic children and adolescents: A scoping review

LAY ABSTRACT

Autistic children and teenagers are, on average, absent from school more than their peers. The aim of this review was to provide an overview of the research on absence from school in autistic learners in primary and secondary school, to help guide future research. We sifted through 4632 reports and found 42 studies with a focus on school absence and autism. We looked at how, when, and where the studies were conducted. We also summarized the results and outlined how absence was measured in the studies. Absence from school may lead to problems later in life, like incomplete education and unemployment. It is therefore important to know how common this problem is among autistic learners, what the reasons may be, and what type of support they need. The studies were from high-income countries and were mainly published in the last 10 years. Studies based on school registers from the United States and the United Kingdom clearly showed that children and teenagers with autism had higher risk of school absence than those without autism. Absence was often linked to problems with mental health or additional neurodevelopmental conditions. Several studies also showed that absence in autistic children and adolescents was related to problems in school, like bullying or lack of knowledge about autism. Support programs were only evaluated in a few studies with a small number of study participants. We conclude that more research is needed to better understand why autistic learners are absent and what they need to thrive in school.

School refusal behavior in children and adolescents: a five-year narrative review of clinical significance and psychopathological profiles

The aim of the study was to explore the clinical significance of school refusal behavior, its negative impact on psychological well-being of children and adolescents and its relationship with the most common psychopathological conditions during childhood and adolescence (e.g. neurodevelopmental disorders, psychiatric disorders). School refusal behavior refers to a distressing condition experienced by children and adolescents that compromise regular school attendance and determine negative consequences on mental health and adaptive functioning. A narrative review of the literature published between January 2019 and March 2023 was conducted. Ten studies (n = 10) were included from a literature search of the electronic databases PubMed, CINAHL, PsycInfo, MedLine, and Cochrane Library. The results indicate that school refusal is highly present in neurodevelopmental disorders such as autism and attention-deficit/hyperactivity disorder due to the presence of behavioral problems and deficits in communication skills. As for psychiatric disorders, school refusal appears to be highly common in anxiety disorders, depressive disorders, and somatic symptoms. We also found that school refusal behavior may be associated with various emotional and behavioral conditions that act as risk factors. Especially, but are not limited to, it may be associated with a diminished self-concept, exposure to cyberbullying, specific affective profiles and excessive technology usage. Our results indicate that school refusal is a condition with many clinical facets. It can be attributed to both vulnerability factors, both temperamental and relational, and to various psychopathological conditions that differ significantly from each other, such as neurodevelopmental disorders and psychiatric disorders. Recognizing these aspects can improve the implementation of patient-tailored therapeutic interventions that are consequently more likely to produce effective outcomes. The therapeutic intervention should facilitate the recognition of cognitive biases regarding school as a threatening environment, while regulating negative emotions associated with school attendance. Additionally, therapeutic intervention programs linked to social skill training and problem-solving training, conducted directly within the school setting, can enhance children's abilities to cope with academic performance and social relationships, ultimately preventing school refusal.

Collateral Damage: The Impacts of School Exclusion on the Mental Health of Parents Caring for Autistic Children

Despite legislative and policy mechanisms that promote inclusion in education for children with disabilities, many students still experience exclusion from the education setting. For example, autistic children are more likely than their neurotypical counterparts to be expelled or suspended from school or to refuse to attend school on an ongoing basis. This situation gives rise to various challenges for their parents. This discursive paper synthesizes current knowledge on school exclusion involving autistic children, including the causes and consequences of exclusionary practices. The paper also considers the negative impacts of these exclusionary practices on the emotional and psychological well-being of parents and caregivers. Mental health nurses who understand the issues related to school exclusion can better support the educational, social, and developmental needs of autistic children and the mental health needs of parents or caregivers.

Social and Behavioural Outcomes of School Aged Autistic Children Who Received Community-Based Early Interventions

The school-age outcomes of autistic children who received early interventions (EI) remains limited. Adaptive functioning, social, peer play skills, problem behaviours, and attitudes towards school of 31 autistic children who received community-based group early start Denver model (G-ESDM) were compared to 28 age matched autistic children who received other community interventions. Similar adaptive behaviours, social skills, problem behaviours and attitudes towards school were found. Play disruption was the only dimension of play to differ; children that received community interventions demonstrated higher levels of play disruption compared to the G-ESDM group. Children had pervasive challenges in adaptive behaviour, social and play behaviour at school, irrespective of EI type. Thus, ongoing provisions are needed to support development into the school years.

Practitioner Review: Signposts for Enhancing Cognitive-Behavioral Therapy for School Refusal in Adolescence

Factors associated with adolescent development influence the occurrence and presentation of school refusal (SR). Cognitive-behavioral therapy (CBT) manuals for the treatment of SR account for these developmental issues to varying degrees. Some multimodal treatments aim to address the complexity of adolescent SR by incorporating interventions alongside CBT, such as medication, inpatient treatment, and educational support in a special setting. However, CBT manuals and multimodal treatments appear to fail to help approximately one-third to two-thirds of adolescents, with respect to achieving regular school attendance. This paper provides an overview of suggestions in the literature for improving treatment for SR, with a focus on adolescent SR. Seven signposts emerge from the literature, namely, increased number or frequency of sessions, greater attention to social anxiety disorder and social functioning, greater attention to depression, greater attention to emotion regulation, careful consideration of the role of parents, greater attention to parent-adolescent communication and problem-solving, and the use of alternative educational settings. Professionals may find these signposts helpful when planning and delivering treatment for SR in adolescents. Research is needed to determine the benefit of including one or more of these adaptations alongside an existing SR treatment.

"He's shouting so loud but nobody's hearing him": A multi-informant study of autistic pupils' experiences of school non-attendance and exclusion

Background and aims

Children and young people on the autism spectrum frequently report a range of negative educational experiences and face disproportionally high rates of school non-attendance, including school avoidance and permanent exclusion, which can have a significant impact on their well-being as well as educational and broader life outcomes. To date, few studies have examined the full range of proximal (child, parent/family, school levels) and distal (community and society levels) barriers to ensuring the school attendance and the inclusion of autistic pupils. The current study sought to do just that by examining autistic young peoples' school non-attendance and exclusion experiences from the perspectives of multiple informants.

Methods

We recruited 12 autistic pupils, who had previously experienced school avoidance and/or exclusion, from one local authority in England, United Kingdom. We conducted semi-structured interviews with the young people themselves, ten of their parents, eight of their current teachers and nine local authority professionals, including six educational psychologists and three specialist autism teachers. We analyzed interviewees' responses using reflexive thematic analysis.

Results

Interviewees gave overwhelmingly negative accounts of autistic pupils' school non-attendance and exclusion experiences. Our analysis identified a range of school-related factors they felt led to, or exacerbated, negative experiences in their former mainstream schools, and which ultimately led to their or their children's school non-attendance. It also went further to identify distal factors, including fragmented educational experiences, parents "fighting" against a complex bureaucratic system to secure appropriate education for their children, and limited professional involvement.

Conclusions

Our findings emphasize the importance of examining the broader context in which autistic pupils are embedded and demonstrate that such pupils are able to successfully attend-and even enjoy-school when they receive the appropriate care and support.

Implications

Schools and local authority professionals should seek to work in partnership with parents and autistic pupils to secure the necessary support for their inclusion in mainstream education. Government policy should support the provision of sufficient local authority professionals to adopt a more proactive approach to mitigate autistic pupils' avoidance of and exclusion from school.

Child and Parental Mental Health as Correlates of School Non-Attendance and School Refusal in Children on the Autism Spectrum

Children on the autism spectrum miss more school than their peers, but limited work has explored why this may be. This study aimed to document the frequency at which children on the autism spectrum miss half and full days of school and the reasons for these absences. Parents of 106 school-aged children on the autism spectrum completed online questionnaires on rates of school non-attendance, family factors, child anxiety, and parental mental health. On average across a four week period, children missed 6 full days of school. The most common reason for full-day absences was school refusal and for half-day absences was medical/therapy appointments. Parental employment status, increased child age, child anxiety, and differing aspects of parental mental health were identified as correlates of specific subtypes of school non-attendance.

Developmental Issues Associated with Adolescent School Refusal and Cognitive-Behavioral Therapy Manuals

It is important to consider developmental issues when addressing school refusal (SR) in adolescence. Referral rates appear to be higher among adolescents relative to children, and treatment appears to be less effective among adolescents. This paper provides an in-depth review of developmental issues associated with adolescent SR and treatment via cognitive-behavioral therapy (CBT). It begins by considering the reasons for the higher referral and poorer treatment outcomes, including the higher level of absenteeism in adolescence, higher rates of concurrent social anxiety disorder and depressive disorder, and the developmental challenges inherent to adolescence. Such challenges include increased academic and social demands in the secondary-school environment, and increasing autonomy which may contribute to family conflict. These developmental issues may potentiate and exacerbate an adolescent's difficulty attending school, make it difficult for families to cope, and complicate practitioners' efforts to provide effective treatment for SR. Further, the review describes CBT manuals for SR and the extent to which they are developmentally sensitive. There are five CBT manuals, which vary in their sensitivity to developmental issues. Various multimodal treatments employ interventions in addition to CBT, such as medication or inpatient treatment, to address the complexity of SR in adolescence. Nevertheless, nonresponse to treatment for adolescent SR ranges from one-third to two-thirds of youths. Attention thus needs to be given to ways of improving treatment outcomes.

The inverse association between psychological resilience and emerging school refusal among bullied autistic youth

BACKGROUND

Autistic youth are often bullied at school, which may lead to school refusal (SR). Currently, there is little research on factors that may help prevent SR among autistic youth. To advance theory-driven preventative interventions, this study examined associations between psychological resilience and emerging SR (ESR) among autistic youth bullied at school.

METHODS

Fifty-eight autistic boys in elementary school (grades 1-6; n = 36) or secondary school (grades 8-11; n = 22) who were bullied at school responded to an online survey, as did their mothers. Boys reported on the experience of being bullied, psychological resilience (via the Social Emotional Assets and Resilience Scale), and ESR. Their mothers provided information regarding the boys' Autism Spectrum Disorder (ASD) diagnosis.

RESULTS

Fifty-six percent of this sample of bullied autistic youth displayed ESR. For the secondary school boys there was a significant inverse relationship between psychological resilience and ESR, principally via two characteristics of psychological resilience: 'controlling negative thoughts' and 'remaining calm when angry'. No significant relationship was found between psychological resilience and ESR among elementary school boys.

CONCLUSION

Longitudinal research is needed to determine whether psychological resilience serves as a factor protecting against the emergence of SR among autistic youth who have been bullied.

Form, Function and Feedback on the School Refusal Assessment Scale-Revised in Children on the Autism Spectrum

School refusal is more prevalent in children on the autism spectrum than among their peers. The function of school refusal can be explored using the school refusal assessment scale-revised (SRAS-R) but its relevance to children on the spectrum has not been investigated. Parents of 121 children (M age 11.9 years) on the autism spectrum completed the SRAS-R and provided feedback on it applicability. Confirmatory factor analysis suggests unsuitability of the original four-factor structure proposed for neurotypical students. Only 41.7% of parents considered the questionnaire an adequate method for reporting on school refusal in children on the autism spectrum with the majority (90%) identifying additional questions to evaluate factors associated with school refusal in autism.

Direct and Inverse Correlates of Post-Traumatic Stress Disorder among School-Age Autistic Boys

Young people with autism are often bullied at school, a potential direct correlate of Post-Traumatic Stress Disorder (PTSD). This may be compounded by their difficulties in social interaction. Alternately, some of these young people may develop ‘coping strategies’ against bullying that may have an inverse association with PTSD. As a vulnerable population for PTSD, a sample of 71 young males with autism were surveyed for their self-reported experiences of being bullied at school, their coping strategies for dealing with this bullying, and their own evaluations of the severity of two of the key diagnostic criteria for PTSD. Their mothers also provided a rating of the severity of the three major diagnostic criteria for autism for these boys. Over 80% of this sample had been bullied, and there was a significant direct correlation between this and PTSD score, and between their mother-rated severity of the boys’ social interaction difficulties, but also a significant inverse correlation between their coping strategies and PTSD score. There were differences in these relationships according to whether the boys attended elementary or secondary school. These findings hold implications for the identification, assessment and support of autistic youth at risk of PTSD.