Brief Report: Predictors of School Refusal Due to Bullying in Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder

School refusal: Considerations for the primary care NP

ABSTRACT

School refusal refers to child- or adolescent-motivated refusal to attend school or remain in school for the duration of the school day. Importantly, the child or adolescent does not conceal their absence from school from their caregivers. Root causes for school refusal include anxiety, mood disorders, untreated learning disorders, and social difficulties. Long-term outcomes of school refusal include further social withdrawal, ongoing mental health issues, and unemployment. This article reviews the differences between school refusal and other types of chronic absenteeism, and it describes behaviors that may manifest in a child or adolescent who avoids attending school. The primary care provider's role in evaluation and treatment of this population is discussed.

Severity of inattention symptoms, experiences of being bullied, and school anxiety as mediators in the association between excessive short-form video viewing and school refusal behaviors in adolescents

Background

Recent years have seen an increase in school refusal behavior among adolescents, potentially due to factors like excessive short-form video viewing, bullying, and school anxiety. Limited research has investigated how these factors contribute to school refusal behavior. This study used random forest regression, path analysis, and network analysis to identify key variables and pathways leading to school refusal behavior.

Methods

In this cross-sectional questionnaire-based study, 2,056 (996 male, 1,060 female, mean age: 14.79 ± 1.24 years) middle and senior high school students were asked to complete the School Refusal Behavior Assessment questionnaire to assess school refusal behavior features, the Excessive Short-Form Video Viewing Scale as well as self-reported viewing times during leisure days to assess excessive short-form video viewing, the SNAP-IV Rating Scale to assess the severity of inattention symptoms, and the self-administered questionnaires to assess experiences of being bullied and school anxiety.

Results

The prevalence of school refusal behavior in the surveyed adolescents was found to be 31.9% [95% confidence interval (CI): 29.8-33.9%]. In terms of significance, the severity of inattention symptoms exhibited the greatest predictive power, while excessive short-form video viewing accounted for the most variance. Path analysis revealed that excessive short-form video viewing not only directly affects school refusal behavior features but also does so indirectly through severity of inattention symptoms and school anxiety. Key bridge factors in this pathway include intense fear and anxiety associated with school attendance, manifesting as somatic symptoms and avoidance behaviors.

Conclusion

The findings indicate that not only does excessive short-form video viewing directly influence school refusal behavior features in adolescents, but it also indirectly impacts these features through mechanisms involving severity of inattention symptoms and school anxiety. The bridge factors highlight potential targets for interventions among the SRB features and predictors.

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.

Using Life Course Theory to Explore the Association Between Autistic Traits, Child, Family, and School Factors and the Successful Transition to Secondary School

Life Course Theory contends that school transitions can interrupt academic and wellbeing trajectories, depending on child, family, and school factors. Hierarchical regression analyses examined how autistic traits were associated with school transition outcomes. Autistic traits explained 12% of the variance in Quality of Life (QOL), 24% of the variance in mental health and 9% of the variance in school belonging. When autistic traits were accounted for, gender was a significant predictor of changes in QOL whereas changes in school belonging were predicted by cognitive functioning, parent education, school attendance and school refusal. Changes in mental health after transition were mostly predicted by family factors including family structure, family functioning and parent education but were also significantly predicted by sleep problems.

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.

School refusal: mapping the literature by bibliometric analysis

School refusal is considered a risk factor for academic, social, and personal situations, such as school dropouts. Studies have been carried out on school refusal for almost 50 years. However, general research trends have not been mapped yet. This study summarizes the bibliometric analysis of scientific collaborations and prevalence across locations by country and institution, leading researchers, journals, and trends (keywords) in school refusal research. The United States, Japan, Spain, and England are the countries that stand out in terms of school refusal. It can be said that the Journal of American Academy of Child and Adolescent Psychiatry, Cognitive and Behavioral Practice, and Frontiers in Psychology are important journals that publish on school refusal. Researchers named Christopher A. Kearney, Carolina Gonzálvez, Jose Manuel Garcia-Fernandez, David A. Heyne, and Brigit M. Van Widenfelt have been found to have more intensive studies and collaborations on school refusal. The authors keywords common use for school refusal; are truancy, school absenteeism, adolescence, school attendance, school phobia, autism spectrum disorder, and bullying. The findings show that school refusal is a current research area, and scientific collaborations continue to be established. The findings reveal all the details of the school refusal research.

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.

"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.

Mindfulness Interventions for Attention Deficit Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition impacting children and adults. Current treatments are limited and there is increasing interest in the use of mindfulness, which is growing in popularity. Previous systematic reviews have typically focused on specific ages, outcome measures or interventions. The current review aimed to take a more comprehensive approach. Title and abstract searches were performed in five databases for randomized and non-randomized controlled trials or pre-post studies with participants with an ADHD diagnosis or a score above a clinically relevant cut-off on a validated ADHD measure. Studies had to measure symptoms of ADHD, global or social functioning. Extraction of key information including participant status (i.e., diagnosis, scale scores, comorbidities, medication use), study design, and outcome measures was conducted. Effect sizes (Hedge’s g) were calculated and where a measure had been used in at least three studies with the same population, meta-analyses were considered. Twenty-nine studies were initially identified, with seven deemed poor quality and removed from further analysis leaving, 22 studies containing data from 1237 children and adults with ADHD along with data from 525 family members. The data indicate possible benefits of mindfulness on self-compassion, quality of life, wellbeing, depression, and anxiety. The findings also suggest that mindfulness may also improve ADHD symptoms, executive function, problematic behaviours, and emotional dysregulation, although results vary by age of patient and measures used. Parent stress and parenting style have received limited attention, highlighting the need for more studies in these areas. Whilst the data presented suggest that mindfulness may be beneficial, the evidence base is not as strong as the popularity of the approach. Many of the studies lacked blind assessment, adequate randomization, or suitable control conditions. As such high-quality controlled studies considering medication, other psychosocial interventions, use of active and in active controls and comorbidity as well as longer follow-up periods, are needed to confirm this.

School attendance problems in adolescent with attention deficit hyperactivity disorder

Introduction: A link between having a neurodevelopmental disorder, such as attention deficit hyperactivity disorder (ADHD) and school absenteeism, has been found in previous studies. Why ADHD poses a risk for absenteeism remains unclear, and insight into the mechanisms of the association is needed. The aim of the present study was to investigate school attendance problems (SAP) and both the symptoms related and the perceived reasons for them, as reported by adolescents with ADHD (n = 95), compared with neurotypical adolescents (n = 1,474). Method: The current study (N = 1,569) was part of the School absence in Finland-project. SAPs were measured with the Inventory of School Attendance Problems (ISAP). The ISAP questionnaire contains a symptom scale (ISAP S) and a function scale (ISAP F), which shows if and how the symptoms impacts school attendance. A linear mixed effects model was used to analyze outcomes on the ISAP factors, controlling for background variables living status, gender, other diagnoses, highest level of education for the parent and age. Results: Results show that adolescents with ADHD had been more absent from school compared to neurotypical adolescents during the prior 12-weeks. Adolescents with ADHD showed significantly more symptoms of agoraphobia/panic, problems within the family and problems with parents than neurotypical peers. The symptoms separation anxiety, agoraphobia/panic, aggression, problems within the family and problems with parents more often were perceived as the reason for SAP (ISAP F). Discussion: The results are in line with our initial hypotheses and previous studies. Because of the low response rate on the ISAP F scale, the results regarding reasons for SAPs should be interpreted with caution. Future research could examine specific preventive actions of SAPs for adolescents with ADHD, and different subtypes of ADHD.

Bullying experiences and mothers’ responses to bullying of children with autism spectrum disorder

Despite the fact that children with disabilities generally have been shown to be at a greater risk of bullying, which include physical attacks and threats, being picked on and teased and verbal abuse, there is still a need to understand bullying of children with autism spectrum disorder (ASD) and the strategies used by parents to support them in tackling this issue. This study aims to investigate the type and level of occurrence of bullying and parental support for children aged five with ASD who suffer from bullying. This study used both quantitative and qualitative analysis; a questionnaire, distributed to mothers of children with ASD, adopted from the Bullying for ASD Survey developed by Chen and Schwartz (Focus Autism Other Dev Disabil 27(4):200–212, 2012) measured types and frequency of bullying and parental support. An open-ended question was added to the survey to enable parents to write about the ways in which their child was bullied and the ways in which they supported their child. The results showed that while children suffered from all types of bullying, especially being picked on, being excluded and called names. Parental support showed a higher prevalence of involving peers and teachers for the prevention of bullying as well as avoiding strategies which included avoiding bullies and none of the mothers encouraged their children to stand up to bullies.

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.

Confirming the Validity of the School-Refusal Assessment Scale-Revised in a Sample of Children With Attention-Deficit/Hyperactivity Disorder

Children with developmental disorders, such as attention-deficit/hyperactivity disorder (ADHD), are at high risk of school-refusal behavior (SRB) compared with their peers. One of the most used scales to assess SRB is the school refusal behavior scale – revised (SRAS-R). The SRAS-R has demonstrated good psychometric properties when used with the general population of children, but, recently, its validity has been questioned when used with children with developmental disorders. We tested the psychometric properties of the SRAS-R parental reports in 96 children with ADHD (M_age = 12.4; SD = 1.7, 61.5% boys). Results showed good model fit and internal consistency for the original four-factor structure. Three of the factors were strongly correlated, suggesting that SRB among children with ADHD is caused by several factors.

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.