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Signposts for School Refusal Interventions, Based on the Views of Stakeholders - Continuity in Education

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Continuity in Education is an open access, peer reviewed journal for the education of children and young people with medical and mental health needs. In line with a biopsychosocial model of health, education and psychological development, the journal reports on different contexts, which may include education in a hospital community or home setting, in urban or rural areas, within different educational systems or structures, across different countries, jurisdictions, and socio-cultural settings, and during different life phases of the individual. The journal aims to focus on the interactions between education and human development in the fields of well-being, resilience, future life choices and opportunities, social and emotional well-being, cognitive and metacognitive learning strategies, and mental health improvement. The journal is open to all contributions that deepen the concept of learning and education as protective factors in the life of young people facing adversities. The concept of continuity in education is also extended to education delivered in other contexts where children and families are living with some kind of disruptive event in their life. Sign up to the mailing list for news from the journal.

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feduc-04-00061.pdf

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Glenn A. Melvin 1,2*, David Heyne ³, Kylie M. Gray 2,4, Richard P. Hastings 2,4, Vaso Totsika 2,4,5, Bruce J. Tonge 2,4 and Mina Mirjana Freeman ⁴

School of Psychology, Faculty of Health, Deakin University, Burwood, VIC, Australia

Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, United Kingdom

Developmental and Educational Psychology Unit, Faculty of Social and Behavioural Sciences, Institute of Psychology, Leiden University, Leiden, Netherlands

Department of Psychiatry, Centre for Developmental Psychiatry and Psychology, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia

Division of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom

Absence from school jeopardizes children's and adolescents' education and their social and emotional development. Proximal and distal individual, parental, familial, and environmental factors have been linked to absenteeism and the development and maintenance of school attendance problems. The complex interaction among these factors necessitates a multifactorial approach to understanding school absenteeism and attendance problems. The current paper builds on recent calls to apply bioecological systems frameworks when studying risk factors for school absenteeism and attendance problems. The Kids and Teens at School (KiTeS) Framework presented here is an application of Bronfenbrenner's bioecological systems model, incorporating candidate factors of particular relevance to school absenteeism and attendance problems. The current paper is also a response to the Warnock report which highlighted the need to individualize educational supports for children and adolescents with disabilities, to foster optimal educational outcomes. The KiTeS Framework is an inclusive framework, inclusive of students with and without disabilities. It is envisaged that the KiTeS Framework will provide guidance to researchers aiming to improve understanding of the factors influencing absenteeism among all school-aged students, including those from minority or vulnerable populations.

Introduction

School, as construed by any culture, is essential for the cognitive and social-emotional development of all children and adolescents (hereafter referred to as youth). It represents preparation for life beyond school, irrespective of the youth's abilities or disabilities (Warnock Report; Department for Education and Science, 1978). Attending school can be understood as a behavior but also as a developmental outcome because it is a marker of the youth's developmental capacity to separate from their caregiver and be engaged at school.

Poor school attendance predicts lower academic achievement over time ( Hancock et al., 2013) and subsequent school drop out ( Barrington and Hendricks, 1989; Schoeneberger, 2012). Those who leave school early are at greater risk of long term negative outcomes, such as reduced employment and economic security, poorer mental and physical health, and lower life expectancy, compared to youth who complete schooling ( Rumberger, 2011).

Absenteeism appears to be a universal problem. In the UK in 2016-17, almost 11% of youth in state-funded primary and secondary schools were classified as persistent absentees for having missed 10% or more of school ( United Kingdom Department of Education, 2018). In the US chronic absenteeism has been described as a "hidden crisis," with nationwide data showing that 16% of youth had absences of 15 or more days during the 2015-16 school year ( U.S Department of Education, 2016). An Australian report concluded that ~30% of youth were at some educational risk due to being absent from school for 10% or more of the time ( Western Australia Auditor General's Report 16, 2015). In rural Karnataka, South India, 8% of lower caste adolescent girls reported being frequently absent from school (four or more days missed in a month; Prakash et al., 2017). A study of youth in Mozambique found that 36.6% of those surveyed reported being truant at least 1 day during a 30 day period ( Seidu, 2019). Research conducted by the Consortium for Research on Educational Access, Transitions, and Equity identified high rates of absenteeism in India and Ghana ( Lewin, 2011). As the aforementioned studies illustrate, different cut offs are used to define when absenteeism becomes problematic. This is an important issue as Skedgell and Kearney (2018) found that associations between problematic levels of absenteeism and contributing factors differ according to the cut-off applied (1, 10, 15% absence).

While acknowledging that a consensus has not yet been reached on an appropriate cut-off to define problematic absenteeism, a body of research shows that a broad range of individual, parental, familial, and environmental factors are implicated in absenteeism and school attendance problems (SAPs) ( Kearney, 2016). Given this broad range of factors spanning multiple contexts, some researchers have proposed bioecological models to inform approaches to prevention and intervention ( Lyon and Cotler, 2009; Doren et al., 2014; Guralnick, 2015; Gottfried and Gee, 2017). Bioecological models typically position the individual at the center of a nested hierarchy of environments that are understood to influence the individual's development over time ( Bronfenbrenner, 1977; Bronfenbrenner and Morris, 2006). These environments extend outward from the most immediate contexts experienced by the individual (e.g., home, school) to broader contexts which impact on the individual and their immediate environments in more or less direct ways (e.g., educational policies, overarching societal, cultural, and historical contexts).

Reasons for and Types of Absenteeism

Reasons for school absenteeism vary greatly. For example, students may be absent due to an illness or medical appointment; anxiety about being away from parents or being amongst other youth at school; difficulty with school work or disinterest in learning; because parents keep a child at home; family transport problems; and the school's exclusion of youth engaged in problematic behavior at school. Often, absences are differentiated according to whether they are excused (e.g., illness) or unexcused (e.g., truancy), and there is some evidence that risk for academic impairment is greater for students with unexcused absences relative to those with excused absences ( Gottfried, 2009; Hancock et al., 2018a). In practice and research, it is difficult to reliably establish whether absence is excused or unexcused, and policy and practice differ within and between countries. Moreover, the fact remains that absence for any reason is a risk factor for negative student outcomes ( Gottfried, 2009; Hancock et al., 2013).

SAPs are often differentiated by type. Four types described by Heyne et al. (2019) are school refusal, truancy, school withdrawal, and school exclusion. There is some scientific support for differential associations between psychosocial risk factors and types of SAPs ( Heyne et al., 2019). However, most research into the multiple determinants of absenteeism does not usually account for likely differential relationships between risk factors and different types of absenteeism. Rigorous research accounting for types of absenteeism may reveal that specific risk factors have weaker or stronger relationships with absenteeism contingent upon the type of absenteeism under investigation.

Absenteeism in Disadvantaged Populations

There is a paucity of research addressing absenteeism among youth with IDD, despite the increased risk for absenteeism in this group. However, prior research has demonstrated that youth with IDD have elevated known risk factors for absenteeism such as higher rates of chronic and multiple health conditions and health care utilization relative to youth without IDD ( Boulet et al., 2009; Schieve et al., 2012). The complex health needs of IDD youth may partly explain their higher rates of school absenteeism. At the same time, some youth with IDD may have a decreased risk for particular types of SAPs. For example, youth with moderate to severe intellectual disabilities may be less likely to truant from school because they may find it more challenging to plan out-of-school activities and to conceal their absence from parents and school staff.

A few studies have addressed the question of whether the reasons for absence differ between disadvantaged and non-disadvantaged populations. For example, Havik et al. (2015) reported a tendency for youth with special educational needs to explain their own absences in terms of truancy rather than school refusal. Maynard et al. (2017) reported divergent risk patterns for different racial/ethnic groups of truanting youth. One finding was that non-Hispanic White youth using illicit drugs were at higher odds of truanting relative to those not using illicit drugs, whereas this difference was not observed among African-American youth and Hispanic youth.

ORGANIZING Risk Factors for Absenteeism

Researchers across the fields of education, psychology, mental health, sociology, and juvenile justice have identified a broad range of individual, peer, family, school, and environmental factors associated with school absenteeism and SAPs ( Kearney, 2008, 2016). These factors include but are not limited to student physical and mental health ( Egger et al., 2003; Allison and Attisha, 2019), family and neighborhood socio-economic status (SES; Zhang, 2003; Gottfried, 2014), family functioning ( Carless et al., 2015), parent mental health ( Bahali et al., 2011), school climate ( Hendron and Kearney, 2016), and social norms and practices ( Prakash et al., 2017). As noted above, given the diversity of factors, some researchers have proposed multi-systemic approaches to understand and respond to absenteeism, aiming to integrate knowledge gained across various fields ( Lyon and Cotler, 2009; Kearney, 2016; Guralnick, 2017; Prakash et al., 2017). It has been argued that models based on bioecological and developmental systems, which attend to the interaction of factors across multiple contexts, offer a useful way to navigate the complexity of absenteeism and SAPs ( Benner et al., 2008; Lyon and Cotler, 2009; Doren et al., 2014; Guralnick, 2015).

Indeed, research indicates that a combination of risk factors may better explain the development and maintenance of absenteeism and SAPs, with no single factor determinative ( Ingul et al., 2012; Hancock et al., 2018b; Skedgell and Kearney, 2018). For example, Gottfried and Gee (2017) applied Bronfenbrenner's bioecological systems model to examine the determinants of chronic absenteeism in US pre-school students. Factors across various domains, including child attributes and environmental factors, interacted in their influence on chronic absenteeism. The authors found that students who were broadly defined as having a disability (based on school records indicating an individualized education program) and who were in the low SES group had lower odds of being chronically absent than low SES students without disability. This finding was somewhat unexpected given prior research linking low SES to absenteeism and showing higher rates of absenteeism among students with disabilities ( Ingul et al., 2012; Balkis et al., 2016; Gottfried et al., 2017). Gottfried and Gee (2017) speculated that parents of pre-school children with disabilities and from low SES environments may place emphasis on their child being at school to receive specialized services they could not otherwise afford. The study provides a useful example of how individual level factors (e.g., child's age, disability status) can combine with factors at other levels (e.g., SES, access to services) to influence attendance.

According to Bronfenbrenner's bioecological systems model, human development is driven by ongoing interactions between the person and elements of their immediate environment, referred to as proximal processes. For school-aged youth, proximal processes related to absenteeism and SAPs include the interactions they have with parents, siblings, friends, and peers, as well as their engagement in morning and evening routines, learning, and extra-curricular activities. The impact of proximal processes on development is understood to vary as a function of individual characteristics (e.g., social skills, personality) and variables spanning multiple ecological contexts (e.g., family, school) as well as broader social contexts and changes over time ( Bronfenbrenner, 1977; Bronfenbrenner and Morris, 2006). Accordingly, the fundamental elements of bioecological models are referred to as process-person-context-time.

Bioecological models typically depict the child embedded in a hierarchy of systems. Immediately surrounding the child is the microsystem, the environments in which proximal processes occur (e.g., family, school, community). Surrounding the microsystem is the mesosystem which is composed of associations between elements of the child's microsystem, such as connections between parents and teachers. At the next level is the exosystem encompassing those settings that influence elements of the microsystem but are not experienced directly by the child (e.g., a parent's work setting; parent and sibling social networks; local health and social services, and infrastructures). Additional levels include the macrosystem and the chronosystem. The macrosystem encompasses broader cultural and institutional norms and beliefs and SES (e.g., family SES; community attitudes to people with disabilities). The chronosystem encompasses the influence of time on development (e.g., timing of significant events; changes in systems over time) which can manifest across a number of domains including cultural and societal values, community attitudes, government policies, and economic stability.

The interplay of proximal and distal factors on school attendance can be illustrated by the proximal processes involved in preparing for school in the morning. The morning routine typically involves some level of cooperation between the child and family members and may be influenced by many individual child characteristics such as age, functional abilities, and mental and physical health. Such child factors may interact with the mental health and wellbeing of parents as well as the family's functioning ( Egger et al., 2003; Bahali et al., 2011; Carless et al., 2015). A depressed parent who lets their anxious child stay at home to give them "a day off" may base their decision, in part, on their own need for support or the desire to avoid the stress associated with getting their child to school in the morning. In turn, a child with separation anxiety who is allowed to remain home is relieved of their anxiety when they observe their parent and feel assured that the parent is safe. Exosystem factors such as a parent's employment ( Ingul et al., 2012), school start times ( Bowers and Moyer, 2017; McKeever and Clark, 2017), and transport options ( Gottfried, 2017) might also exert an influence on proximal processes. Such distal factors may differentially influence attendance outcomes for special populations such as indigenous students or those with a disability. It is well established that youth with IDD, for example, are more likely than typically developing peers to live in low income, single parent, or unemployed households and poorer neighborhoods ( Emerson et al., 2010b). Moreover, socio-economic risk factors are linked to poorer mental and physical health in children with IDD and their parents ( Emerson et al., 2006, 2010a; Emerson and Hatton, 2007). In turn, poor mental and physical health in parents and children are known risk factors for absenteeism and SAPs ( Allison and Attisha, 2019). Bioecological models that focus on the interaction of factors across domains are, therefore, in line with trends in disability research to shift the focus from individual factors to an understanding of how broader cultural and structural factors, including educational settings, impede the development of students with disabilities ( Mittler, 2015).

There have been calls for more research on factors influencing absenteeism and SAPs among disadvantaged populations, such as students from diverse ethnic backgrounds along with those with disabilities, to better understand potentially unique risk profiles ( Zubrick et al., 2006; Lyon and Cotler, 2007; Gee, 2018). Moreover, there is no conceptual framework which is explicitly inclusive of factors relevant to disadvantaged populations. Efforts to improve school attendance, educational outcomes, and lifelong outcomes for these disadvantaged populations requires a better understanding of the determinants of absenteeism.

Research on absenteeism and SAPs in typically developing populations provides a useful starting point for examining the same phenomena in other student sub-groups, including those experiencing disadvantage. However, absenteeism and SAP types and their key risk and protective factors may differ across disadvantaged and non-disadvantaged groups. A comprehensive research framework is needed to ascertain whether there are meaningful differences in the pathways to absenteeism and SAPs between and among the various populations of students. Research informed by a broad framework relevant to all student populations may have important implications for prevention and intervention for absenteeism and SAPs, including family support, school policy, community services, and culturally sensitive school adaptations.

The Kids and Teens at School (KiTeS) Framework-applies Bronfenbrenner's bioecological systems model to facilitate research that builds knowledge about attendance and absence among all school students, including those from disadvantaged populations (see Figure 1). The framework seeks to inform research on the development, maintenance, and alleviation of school absenteeism and SAPs.

Figure 1. The KiTeS bioecological systems framework for school attendance and absence.

The KiTeS Framework

The KiTeS Framework uses the conceptual structure of Bronfenbrenner's bioecological model including micro-, meso-, macro-, exo-, and chrono-systems to organize factors known to influence human development ( Bronfenbrenner and Morris, 2006). We also describe the extant literature in its relationship with the factors included in the framework.

We place youth characteristics operating at the micro- and meso-system level at the center of the KiTeS Framework because of their key influence on the interactions between the individual and their environment (i.e., proximal processes). Bronfenbrenner and Morris (2006) conceptualized person characteristics as demand, resource, and force characteristics. Demand characteristics are features of the person that are directly apparent to others and invite or discourage interactions and reactions. Examples include age, gender, and appearance. Resource characteristics refer to a person's skills, abilities, experiences, and disabilities which can influence the capacity of the person to engage in proximal processes. Force characteristics are considered the shapers of development as they refer to behavioral dispositions that either support or disrupt proximal processes and therefore development. Examples include responsiveness, distractibility, and emotional regulation.

A range of resource characteristics are linked to absenteeism and SAPs, including biological and psychological factors such as functional limitations, acute and chronic illness, mental health conditions and sleep ( McShane et al., 2001; Egger et al., 2003; Houtrow et al., 2012; Hysing et al., 2015; Allison and Attisha, 2019). Specific learning disabilities, IDD, and neuro-developmental conditions are also associated with absenteeism ( Redmond and Hosp, 2008; Gottfried et al., 2017; Black and Zablotsky, 2018).

Self-regulation, a force characteristic according to Bronfenbrenner and Morris' conceptualization, has been found to negatively associate with absenteeism ( Balkis et al., 2016). Similarly, attitudes toward school and perceptions of academic ability have been linked to absenteeism and these might best be viewed as force characteristics given their influence on a student's active orientation toward school ( Green et al., 2012; Balkis et al., 2016). Mental health conditions, including anxiety, mood disorders, and externalizing behavior problems such as inattention, impulsiveness, and hyperactivity are developmentally disruptive and are linked to absenteeism and SAPs ( McShane et al., 2001; Egger et al., 2003; Ingul et al., 2012; Kearney, 2016). While these disorders are considered resource characteristics (Bronfenbrenner and Morris 2006), their symptoms, such as anxiety, low affect, and cognitive impairment impact on force characteristics such as social avoidance, self-regulation, inattention, and motivation and are likely to invite or discourage responses from others and impact the likelihood of proximal processes being initiated or sustained.

The KiTeS Framework identifies a range of parent, family, and school factors at the micro- and meso- levels that may influence proximal processes and factors implicated in absenteeism and SAPs. Important parent factors include parental stress, mental and physical health, and parenting styles ( Dura and Beck, 1988; Corville-Smith et al., 1998; Martin et al., 1999; Hastings, 2002; Herring et al., 2006; Lipstein et al., 2009; Bahali et al., 2011; Woodman et al., 2015). Parental attitudes to school and parental involvement in their child's schooling are also relevant because these factors are linked to youth's academic achievement and school engagement which are factors associated with school attendance ( Newman, 2005; Jeynes, 2007; Doren et al., 2012).

At the family level, family composition ( Bernstein and Borchardt, 1996), family functioning ( Corville-Smith et al., 1998; Carless et al., 2015), and family dynamics ( Kearney and Silverman, 1995) have been linked to absenteeism and SAPs. School factors at the micro- and meso- system levels include aspects of school climate, a multi-dimensional construct encompassing teacher, student, and peer relationships; feelings of safety and inclusion at school; levels of academic and social support; the quality of the school's physical environment; and connections within the broader school community including parents ( Cohen et al., 2009). Positive school climate is associated with a number of positive school outcomes such as academic achievement, fewer student behavior problems, and better attendance rates ( Faircloth and Hamm, 2005; Freeman et al., 2015; Hendron and Kearney, 2016; Roorda et al., 2017; Van Eck et al., 2017).

Exo-system factors related to the school domain such as classroom setting, school type, and school organizational factors also show some links to absenteeism and SAPs ( Gottfried et al., 2017; Lenhoff and Pogodzinski, 2018). For example, Lenhoff and Pogodzinski (2018) found that school organizational effectiveness moderated the influence of demographic and individual level factors (sex, race/ethnicity, special educational status, English language learner status, and economic disadvantage) on absenteeism in US state schools but not in charter schools (publicly funded independent schools). A study by Gottfried et al. (2017) found that the risk of chronic absenteeism was lower for mainstream school students with disabilities (broadly defined by special educational needs and including students with emotional problems) who received instruction in classrooms among a higher percentage of typically developing students (inclusive classrooms) compared to students with disabilities receiving instruction in separate classrooms among fewer typically developing students (exclusive classroom). Further, students who received part-time instruction with a special education teacher in inclusive classrooms were less likely to be chronically absent compared to students who had the same disabilities but were in contact with special education teachers full-time in the inclusive classrooms.

Factors at the exo- and macro- system levels may be particularly salient to disadvantaged populations. Youth with IDD are more likely to be exposed to risks of socio-economic disadvantage such as living in low income or unemployed households, poorer neighborhoods, and single parent households compared to their typically developing peers ( Emerson and Hatton, 2007). These distal factors are considered within the KiTeS Framework given they may exert a particular influence on absenteeism and SAPs in disadvantaged populations.

Within the macro-system, attitudes toward education vary between cultural groups and may impact attendance rates. There is evidence of variability across cultural groups in parent's beliefs and behaviors regarding their children's education which may influence how parents socialize their child to school ( Stevenson and Lee, 1990; Taylor et al., 2004). For example, in a cross-cultural study, Stevenson and Lee found that Chinese and Japanese mothers held higher standards for their child's academic achievement than did American mothers and they also endorsed the importance of academic effort to a greater degree than American mothers. Cultural attitudes toward persons with disabilities also vary. In the Australian multi-cultural context, there is some evidence that cultural groups differ in their acceptance of persons with disabilities ( Westbrook et al., 1993). A report from Victoria, Australia, noted that students with disabilities from culturally and linguistically diverse backgrounds may be missing more school because of cultural views about the benefits and cultural relevance of mainstream education ( Victorian Equal Opportunity Human Rights Commission, 2012). The KiTeS Framework prompts researchers to consider such factors when investigating risks for absenteeism in disadvantaged populations.

With respect to the chronosystem, absenteeism that occurs early in schooling places students at increased risk for absenteeism in later years ( Hancock et al., 2013). Different constellations of risk factors for absenteeism are also likely to be influential at different ages. For example, Skedgell and Kearney (2018) found that rates of absenteeism differed across school grades. Similarly, separation anxiety may be a more influential risk factor for the SAP school refusal at younger ages ( Last and Strauss, 1990). Consideration of chronosystem factors is thus required to achieve a comprehensive understanding of absenteeism and SAPs.

Advancing Research With the KiTeS Framework

The KiTeS Framework, based on Bronfenbrenner's bioecological systems model, offers an inclusive structure to inform research. It highlights the complex array of factors within the micro-, meso-, macro-, and chrono-systems, that may contribute to school absenteeism and SAPs amongst diverse student populations. A strength of the KiTeS Framework is that it demands the consideration of multiple levels of influence on school absenteeism and SAPs by placing the child within a nested framework of interacting systems. The Framework is relevant to many disciplines, including but not limited to education, psychology, psychiatry, pediatrics, disability, youth justice, social work, sociology, and criminal justice and is well placed to inform the development of a multi-disciplinary research agenda for absenteeism and SAPs which the field is currently lacking.

As noted earlier, several student populations experience elevated levels of, and vulnerability to, absenteeism and SAPs, including indigenous youth and those with disabilities. The KiTeS Framework is applicable to all student populations and fosters examination of the interacting factors that may underlie increased risk for different groups of students. The KiTeS Framework is equally applicable to research into protective factors that promote attendance, counteracting risk factors for the development of absenteeism and SAPs. To-date, the literature in the field has had a greater focus on understanding risk factors for absenteeism and non-attendance. However, the development of interventions to prevent and reduce SAPs will need to target both a reduction in risk factors and an increase in protective factors. The Framework offers a comprehensive context for exploring risk and protective factors to help explain absenteeism and SAPs and develop appropriate interventions.

Implications

It is envisaged that the knowledge gained through research guided by the KiTeS Framework will inform the development of interventions to prevent absenteeism and reduce SAPs. Lyon and Cotler (2009) have argued that traditional psychological interventions for SAPs, which largely focus on individual child factors, should be complemented by knowledge of the influence of factors at other levels, such as broader school, family, and policy levels. Research informed by the KiTeS framework might also influence policies and laws on school attendance and absenteeism by yielding policy-relevant research data. Although policies and laws around absenteeism evidently change over time, the empirical basis for these changes appears to be lacking (e.g., Brouwer-Borghuis et al., 2019).

There are scientific and practice advantages associated with the explicitly inclusive objective of the KiTeS Framework, whereby the needs and experiences of disadvantaged populations are acknowledged, including those with special education needs. The complexities of these youths' lives are challenging for researchers and practitioners who wish to understand school absenteeism and SAPs among these youth. An inclusive framework can help reduce inequalities in the longer term by ensuring that organizations and systems are enabled to develop and provide interventions and supports that consider the needs of all children-those with and without disadvantage.

Conclusion

School attendance is important for youths' optimal development. A comprehensive understanding of the complex interplay of protective and risk factors for school attendance and absence is critical. The KiTeS Framework applies Bronfenbrenner's bioecological systems framework to guide research toward an inclusive and multifactorial examination of absenteeism and SAPs. It is hoped that research informed by the framework will yield data directly relevant for enhancing prevention programs, tailoring interventions to the needs of those displaying SAPs, and informing evidence-based policies and laws. In turn, these will help improve school attendance, educational outcomes, and the social and emotional well-being of all youth.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Funding

Preparation of this manuscript was supported by an Australian Research Council Discovery Project Grant DP160101142.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

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The Kids and Teens at School (KiTeS) Framework: An Inclusive Bioecological Systems Approach to Understanding School Absenteeism and School Attendance Problems

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Absence from school jeopardizes children's and adolescents' education and their social and emotional development.

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Belonging Schools | Teach First

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Teach First commissioned a team led by Professor Toby Greany at the University of Nottingham to conduct research to address two questions:

1. What does 'inclusion' mean to pupils, teachers, and leaders?

2. How do relatively more inclusive secondary schools approach and practise inclusion?

The research was carried out in 2022-2023 and included:

a review of literature

focus groups with school and trust leaders

an online survey

detailed case studies of six secondary schools in challenging contexts across England which are achieving relatively good outcomes for both inclusion and attainment

The research highlights that there is no 'one best way' to achieve inclusion but shows how a sample of relatively more inclusive schools adopt an 'inclusion for all' approach founded on equity, relationships and belonging.

The report title - Belonging Schools - highlights the centrality of human relationships underpinned by shared values in all six case study schools. These relationships and values created a sense of belonging - of students being seen, known, cared for, understood and supported in ways which best met their needs - from which inclusion was an outcome.

The report describes the foundations, enablers and specific areas of practice that support inclusion across the case study schools, including through a series of vignettes. It also highlights common challenges to inclusion and poses a set of questions for policymakers to consider.

Download the report to read the findings in full.

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How do relatively more inclusive secondary schools approach and practise inclusion?

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Use of AV1 Robots (Fletcher, Bond & Qualter, 2023)

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Use of AV1 Robots (Fletcher, Bond & Qualter, 2023)

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https://www.tandfonline.com/doi/full/10.1080/02667363.2023.2269082

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(PDF) A Multidimensional, Multi-tiered System of Supports Model to Promote School Attendance and Address School Absenteeism (researchgate.net)

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Abstract

School attendance and completion are significant indicators of health and positive psychosocial development in children and adolescents. School attendance and completion rates remain particularly stifled, however, for students of color, students in poverty, and students with disabilities, among other vulnerable groups. Researchers and educational agencies often focus on student and family mechanisms of school attendance problems with less attention to dominant systems that truly propel school absenteeism. To keep these themes "front and center" for stakeholders, this article summarizes key social forces and social justice issues that impact school attendance problems for marginalized students who are often excluded from many aspects of the educational process. These issues include education deprivation, migration and discrimination, school funding, school discipline, residential mobility and housing insecurity, adverse childhood experiences, school climate, school victimization, access to care, and other barriers to school attendance. Recommendations for research, policy, and intervention are presented as well. These recommendations partly include greater incorporation of various ecological levels, interaction effects, policies to promote school engagement, broader school accountability measures, proactive early warning systems, and culturally responsive multi-tiered system of support interventions.

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1. Department of Psychology, University of Nevada, Las Vegas 4505 Maryland Parkway, Las Vegas, NV, USA

Christopher A. Kearney & Shadie Burke

2. Department of Educational Leadership and Policy, University of Texas at Austin, Austin, TX, USA

Joshua Childs

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All authors contributed to paper conception and writing, and all authors read and approved the final manuscript.

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Correspondence to Christopher A. Kearney.

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Kearney, C.A., Childs, J. & Burke, S. Social Forces, Social Justice, and School Attendance Problems in Youth. Contemp School Psychol 27, 136-151 (2023). https://doi.org/10.1007/s40688-022-00425-5
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Keywords

# data[].attributes.attachment_link.title
Social Forces, Social Justice, and School Attendance Problems in Youth - Contemporary School Psychology

# data[].attributes.attachment_link.description
School attendance and completion are significant indicators of health and positive psychosocial development in children and adolescents. School attendance and completion rates remain particularly stifled, however, for students of color, students in poverty, and students with disabilities, among other vulnerable groups.

# data[].attributes.headline
The unlearning of school attendance - ideas for change. There is need for emerging and new ways of valuing participation in education from pre-school to high school 

# data[].attributes.subject
The unlearning of school attendance - ideas for change. There is need for emerging and new ways of valuing participation in education from pre-school to high school 

# data[].attributes.body
l https://www.frontiersin.org/research-topics/31346/the-unlearning-of-school-attendance-ideas-for-change/magazine#articles

# data[].attributes.attachment_link.title
The Unlearning of School Attendance: Ideas for Change

# data[].attributes.attachment_link.description
This Research Topic on Unlearning Attendance champions a serious look at school attendance and absenteeism. It examines all forms of school attendance problems ranging from school refusal, truancy, school withdrawal, to school avoidance and its correlates of criminal, socio-emotional, developmental, psychological, academic, fiscal, technological, and societal impact.

# data[].attributes.headline
Listening to, and learning from parents in the attendance crisis 

# data[].attributes.subject
Listening to, and learning from parents in the attendance crisis 

# data[].attributes.body
Attendance has always been a symptom rather than a cause, a manifestation of complex issues across the education system and beyond

# data[].attributes.headline
Recent research re neurodiversity, agency, belonging and attendance

# data[].attributes.subject
Recent research re neurodiversity, agency, belonging and attendance

# data[].attributes.headline
Breaking the Boundaries Collective–A Manifesto for Relationship-based Practice

# data[].attributes.subject
Breaking the Boundaries Collective–A Manifesto for Relationship-based Practice

# data[].attributes.headline
(INSA) International Network for School Attendance 

# data[].attributes.subject
(INSA) International Network for School Attendance 

# data[].attributes.attachment_link.readable_text
The International Network for School Attendance

The International Network for School Attendance (INSA) exists for all those who wish to promote school attendance and respond to school attendance problems. It aims to compile, generate, evaluate, and disseminate information, assessment, and intervention strategies.

INSA is run on a voluntary basis but it is growing fast and developing initiatives despite limited resources. Whether you're an academic who'd like to share research, a practitioner looking for successful interventions, or a policymaker keen to link up with colleagues in other countries, INSA is here for you.

A wealth of information is freely available on the website and we encourage you to contribute; get in touch via our contact page. In addition, INSA membership is only 70 EUR per year. Members have access to: videos of webinars and 50+ presentations from the 2019 conference; a Discussion Forum for consultation and collaboration with practitioners and researchers around the world; the quarterly newsletter INStAnt!; and discounted registration for the next conference.

# data[].attributes.attachment_link.title
INSA | International Network for School Attendance

# data[].attributes.attachment_link.description
The International Network for School Attendance (INSA) exists for all those who wish to promote school attendance and respond to school attendance problems. It aims to compile, generate, evaluate, and disseminate information, assessment, and intervention strategies. INSA is run on a voluntary basis but it is growing fast and developing initiatives despite limited resources.

# data[].attributes.headline
School distress and the school attendance crisis

# data[].attributes.subject
School distress and the school attendance crisis

# data[].attributes.body
Our findings suggest that a large number of CYP are being denied access to education due to the emotional distress they experience at school

# data[].attributes.attachment_link.readable_text
Front Psychiatry. 2023; 14: 1237052.

Abstract

Background

The Covid-19 pandemic has brought into sharp focus a school attendance crisis in many countries, although this likely pre-dates the pandemic. Children and young people (CYP) struggling to attend school often display extreme emotional distress before/during/after school. We term this School Distress. Here we sought to elucidate the characteristics of the CYP struggling to attend school in the United Kingdom.

Methods

Using a case-control, concurrent embedded mixed-method research design, 947 parents of CYP with experience of School Distress completed a bespoke online questionnaire (February/March 2022), alongside an age-matched control group ( n = 149) and a smaller group of parents who electively home-educate ( n  = 25).

Results

In 94.3% of cases, school attendance problems were underpinned by significant emotional distress, with often harrowing accounts of this distress provided by parents. While the mean age of the CYP in this sample was 11.6 years (StDev 3.1 years), their School Distress was evident to parents from a much younger age (7.9 years). Notably, 92.1% of CYP currently experiencing School Distress were described as neurodivergent (ND) and 83.4% as autistic. The Odds Ratio of autistic CYP experiencing School Distress was 46.61 [95% CI (24.67, 88.07)]. Autistic CYP displayed School Distress at a significantly earlier age, and it was significantly more enduring. Multi-modal sensory processing difficulties and ADHD (among other neurodivergent conditions) were also commonly associated with School Distress; with School Distress CYP having an average of 3.62 NDs (StDev 2.68). In addition, clinically significant anxiety symptomology (92.5%) and elevated demand avoidance were also pervasive. Mental health difficulties in the absence of a neurodivergent profile were, however, relatively rare (6.17%). Concerningly, despite the striking levels of emotional distress and disability reported by parents, parents also reported a dearth of meaningful support for their CYP at school.

Conclusion

While not a story of exclusivity relating solely to autism, School Distress is a story dominated by complex neurodivergence and a seemingly systemic failure to meet the needs of these CYP. Given the disproportionate number of disabled CYP impacted, we ask whether the United Kingdom is upholding its responsibility to ensure the "right to an education" for all CYP (Human Rights Act 1998).

Keywords: school distress, school refusal, school attendance difficulties, autism, pathological demand avoidance, sensory processing disorder, mental health, ADHD

1. Introduction

" A withered boy who was so afraid, hiding from society in the shade, His solitary cries no-one did hear, his confused mind full of fear. His tortured soul locked inside, with his faded dreams that had died." Damian Milton, Autistic scholar ( 1).

School attendance problems driven by mental health (MH) difficulties are increasingly prevalent in the United Kingdom with the Children's Commissioner's recent Attendance Audit ["Where are England's Children?," ( 2)] estimating that 1.7 million pupils in England were persistently absent (missing over 10% of school sessions) and 124,000 pupils severely absent (missing over 50% of school sessions) in the autumn 2021 term.

School attendance problems underpinned by MH difficulties are, however, not a new phenomenon. Failure by the scientific community to agree a typology for describing attendance problems driven by MH difficulties ( 3) has hindered understanding and support, and led to a phenomena that is poorly described in the literature ( 4). Terms such as "school refusal," "school phobia" and "school avoidance" have been used interchangeably throughout the literature to describe attendance problems, with "school refusal behavior" frequently used as an umbrella term covering anxiety-based school refusal and truancy ( 3).

Terms such as school "refusal" and "avoidance" are, however, rejected by many individuals with lived experience of school attendance problems driven by MH difficulties, as they suggest the behavior is under the control of the young person ( 5-10). Moreover, they do not convey any information regarding the emotional distress associated with school attendance experienced by these children and young people (CYP) ( 6, 7, 11-13) (see Figure 1 ). The term "School Anxiety," which first appeared in the literature in 1959 ( 14), has become increasingly prevalent over recent years, as it goes some way in addressing the above concerns. However, it is narrow, focusing only on the anxiety component of the CYP's experience. This places the focus on treating the CYP's anxiety, as opposed to simultaneously addressing the drivers of this anxiety ( 6, 7, 11, 12).

We propose that attendance problems underpinned by emotional distress are best described as "School Distress" (SD), given that emotional distress associated with school attendance is the core driving feature (see Figure 1 ). This term does not focus solely on the anxiety component of the phenomena, which may be the outcome, rather than the driver, of the distress experienced by the CYP at school. Unlike terms such as "School Refusal," School Distress is person-orientated and, as such, attempts to convey information to individuals surrounding CYP with respect to the child's experience and presentation. We hope that this will intrinsically foster greater understanding and earlier recognition (particularly to early signs of distress), ultimately leading to more empathetic, appropriate support for these CYP.

Historically school attendance problems are considered equally common among boys and girls, with no noted socioeconomic component ( 15). The onset of attendance problems may be sudden or gradual, with possible presentations including children pleading to miss school, displaying physical refusal in the morning, or expressing somatic complaints ( 16, 17).

Although School Distress likely accounts for a significant proportion of school absences, official figures are not available in the United Kingdom, with absences due to MH difficulties not being recorded differently to general absences ( 18). This prevents a full estimation of the scale of the problem. However, even if available, these figures would exclude CYP experiencing School Distress who still manage to attend school but who experience significant distress while there. Some authors estimate that attendance problems due to emotional distress affect around 1% of school-aged children ( 19), although others suggest higher estimates [e.g., ( 15, 20)], likely due to the different conceptualizations used ( 21).

Within current literature, limited research has directly explored the causes of School Distress. Despite this, some potential factors have emerged within small-scale interviews with CYP and their parents, including fear of teacher behavior, noisy and disorganized classrooms, anxiety, isolation, and unpredictability ( 22-24). In recent years, autism and sensory processing difficulties have become increasingly recognized as common characteristics among CYP experiencing school attendance problems ( 25).

1.1. Autism

Autism impacts how individuals makes sense of the world around them. These differences often result in communication breakdowns between autistic and non-autistic individuals, likely due to the differing perspectives between the two neurotypes ( 26, 27). Significant differences in the primary sensory experiences of the autistic lived experience are widely documented [e.g., ( 28)], with previous estimates of sensory processing differences in ~90% of autistic individuals ( 29, 30). Elevated rates of anxiety are also pervasive ( 31, 32).

Strikingly, Ochi et al. ( 33) found 40% of their school 'refusing' participants to be autistic, while Munkhaugen et al. ( 34) identified teacher-reported attendance problems in 42.6% of autistic students, compared to 7.1% of neurotypical (NT) students. Munkhaugen et al. ( 34) also reported that these differences persisted when primary and secondary students were studied separately, and that autistic CYP were absent on significantly more days than their neurotypical peers, indicating greater severity. This aligns with Ochi et al. ( 33) who reported a significantly lower age of onset of attendance problems in autistic children.

Insights into why autistic CYP have disproportionately negative experiences at school, and thus why they appear to be at increased risk of School Distress, are available from multiple sources ( 35-39). Contributing factors overlap with previously identified drivers ( 22-24) and include sensory processing difficulties, feelings of exclusion, lack of teacher understanding, anxiety and demand avoidance.

1.2. Sensory processing difficulties

1.3. Anxiety

Anxiety may also play an important role in the emergence and/or persistence of School Distress for many CYP [e.g., ( 24)], with high anxiety levels commonly noted in CYP experiencing attendance problems [e.g., ( 45)]. For example, Jones et al. ( 46) found significantly greater clinician- and child-reported anxiety severity among school-reluctant CYP, compared to non-school reluctant CYP. Moreover, in a study of Ecuadorian adolescents, Gonzalvez et al. ( 47) found that CYP whose school 'refusal' was strongly linked to avoidance of negative affectivity, escape from aversive social and/or evaluative situations, and/or pursuit of attention, had significantly elevated depression, anxiety and stress. Thus, high anxiety appears to be another characteristic of CYP experiencing School Distress. These studies do not, however, tell us whether high anxiety is a cause or a consequence of CYPs' distressing experiences in school.

As severe symptoms of anxiety frequently co-occur in autistic individuals ( 32), understanding the role of both autism and anxiety (and the intersection between the two) in the development and maintenance of School Distress is likely important in elucidating key drivers of this phenomenon. Similarly, other neurodivergent conditions that also frequently co-occur with anxiety may also heighten the risk of experiencing School Distress [e.g., ADHD ( 48)], as too could a primary diagnosis of anxiety.

1.4. Demand avoidance

Parents of CYP experiencing school attendance problems often highlight their child's difficulties coping with everyday demands as being instrumental in the difficulties faced at school, leading to extreme distress and/or behaviors ( 6). Such demands are omnipresent in the adult-directed mainstream setting, indicating a potential link between School Distress and demand avoidance.

Pathological Demand Avoidance (PDA) was first described by Newson ( 49, 50), to describe a group of CYP who displayed seemingly "obsessive resistance" to everyday demands and an extreme need for control ( 51). Although research is limited, a population cohort study from the Faroe Islands suggested almost 1/5 autistic CYP show some demand avoidant characteristics ( 52). Demand avoidance in adults may be anxiety-driven ( 53), and in CYP these behaviors may be an attempt to increase certainty/predictability in order to alleviate increasing anxiety ( 54). PDA is also described in the literature as 'Extreme Demand Avoidance' (EDA) ( 52), although some advocates suggest 'Rational Demand Avoidance' (RDA) [i.e., as a rational response to one's circumstances ( 1, 55)] or 'Pervasive Drive for Autonomy' ( 56) as more appropriate typology.

Importantly, a key motivation for Newson's recognition of PDA was that a lack of recognition of this " markedly divergent overall presentation...contributes to inappropriate handling and educational methods, since PDA children respond best to very different approaches compared with those suitable for autistic and Asperger children." More recently, Summerhill and Collett ( 57) highlighted anecdotal evidence indicating that when demand avoidant CYP are not identified, their presentation is viewed as defiance and deliberately challenging behavior, leading to school exclusions ( 58), which negatively impacts access to education, social relationships, and MH ( 57).

Moreover, the uniqueness of the demand avoidant profile may explain why a 2018 survey found that 70% of school aged demand avoidant CYP were either not enrolled in school or were unable to tolerate their school environment ( 59). Additionally, Truman et al. ( 60) found that while all parents of autistic CYP described their child's school experiences as overwhelmingly negative, parents of demand avoidant autistic CYP provided markedly more negative descriptions than parents of autistic CYP without demand avoidant profiles. Hence, demand avoidant autistic children may be especially vulnerable to School Distress, perhaps due to their elevated levels of anxiety ( 61) and need for alternative educational methods ( 49, 50), which likely require a flexible, non-directive teaching style ( 62), as pressure to comply with direct demands is well-documented to lead to escalation in emotional reactivity and challenging behavior ( 63).

Interestingly, while the PDA profile is recognized by autism specialist clinicians and academics as an important known range of co-occurring difficulties for many autistic individuals ( 64), PDA has also been documented in other neurodivergent profiles such as selective mutism, language disorders, epilepsy, and, less commonly, in the general population ( 52). Understanding how demand avoidance relates to School Distress, and the parameters discussed above (e.g., neurotype, anxiety, sensory processing differences), is thus important to fully elucidate the factors that contribute to School Distress. To date, however, there is a dearth of academic research exploring this link.

1.5. Current research

In this research, we sought to address the current dearth of understanding in the literature by addressing a number of outstanding questions. More specifically, by comparing CYP who have experienced School Distress with both CYP who attend school without distress and CYP who have never attended a school setting [i.e., Electively Home-Educated (EHE) CYP], we aimed to 1. identify prevalent characteristics of CYP who have experienced difficulties attending school; 2. quantify the proportion of cases of school attendance problems associated with emotional distress; 3. compare anxiety levels, sensory processing difficulties, and demand avoidance profiles between the three groups; 4. explore associations between sensory processing difficulties, anxiety, demand avoidance, and markers of School Distress severity (i.e., duration of School Distress, school attendance rate, age of onset, and impact of school attendance on MH); and 5. assess the level of support received by CYP currently experiencing School Distress.

It is hypothesized that neurodivergent (ND) CYP will be over-represented among individuals with School Distress experience, particularly autistic CYP and CYP with sensory processing difficulties; that anxiety will be prevalent in CYP with School Distress, particularly in autistic, non-autistic ND, and/or demand avoidant CYP; and CYP with more extensive sensory processing difficulties, higher anxiety, and more pervasive demand avoidant profiles will show more severe School Distress than their neurotypical peers.

2. Materials and methods

2.1. Participants

Participants were required to live in the United Kingdom and be parents/carers of school-aged CYP. Initially, 1,055 participants were recruited via volunteer sampling, consisting of 738 parents of children currently experiencing School Distress (Current SD), 209 parents of children who have previously experienced School Distress (Past SD), 83 parents of children who have never experienced School Distress (No SD), and 25 parents of children who have never attended a school setting (Lifelong EHE). An additional 66 parents of CYP who have never experienced School Distress were recruited via prolific.org to ensure the Current, Past, and No School Distress groups were all matched in terms of chronological age, providing an overall sample of 1,121 participants. To assist with age matching, prolific parents with more than one child were instructed to consider their eldest child within the questionnaire. On average, participants completed 77.35% of the survey, with 62.5% completing 100%. Most participants were mothers (97.03%). Table 1 displays key characteristics of the CYP. Figure 2 shows a map of the CYP experiencing School Distress.

Table 1

Characteristic

All

Current SD

Past SD

No SD

Lifelong EHE

n (%)

1,121

738 (65.8)

209 (18.6)

149 (13.3)

25 (2.2)

Respondent's relationship to child (%)

Gender (%)

Ethnic group (%)

Main language (%)

Country of residence (%)

Siblings (%)

Position in family (%)

SEN Support (*Mainstream only)

2.2. Language

Where possible, we use identity-first language (e.g., autistic CYP) ( 65). We defined neurodivergence (ND) for parents as "a term for when someone's brain processes, learns and behaves differently from what is considered 'typical'. Autism is an example of a neurodivergence." We use the term 'non-autistic' to refer to CYP whose parents did not identify them as autistic (be that diagnosed or self/parent-identified), and 'non-autistic ND CYP' for the subgroup of non-autistic CYP who are otherwise neurodivergent. We use the term 'neurotypical' (NT) to refer to CYP whose parent identified them as not being neurodivergent.

2.3. Design

The study employed a case-control, concurrent embedded, mixed-methods design where qualitative data was collected to supplement quantitative data. This was chosen due to the study's exploratory nature, and because the limited literature prevented us from providing fully comprehensive lists of response options to some questions. To collect qualitative data, text boxes were presented within some questions for parents to provide comments. The results reported in this paper are largely quantitative, with some parental comments reported to support understanding. Thematic analyzes and additional data will be reported elsewhere.

2.4. Materials

A bespoke online questionnaire was developed containing four sections and 76 questions. Only certain questions were presented to each respondent, based on their experience of School Distress and survey responses. Questions and response options were developed based upon a comprehensive literature review, and aimed to collate key information about the respondent, their CYP, their CYP's experience of School Distress, and the impact of School Distress on themselves.

This paper will report data from the questions and clinical scales described below. Data relating to how School Distress presents, the reasons underlying School Distress, the efficacy of supports, the consequences of School Distress, and the parental experience will be reported elsewhere.

(1) Demographic information: Participants were asked their relationship to the CYP, and the CYP's country of residence, spoken language, ethnicity, age, gender identity, and number of siblings (with ages). Postcodes were requested and converted into Index of Multiple Deprivation (IMD) Deciles for families living in England ( 66). In accordance with prolific.org data protection policy, prolific participants provided only their IMD decile.1

(2) School attendance problems: Participants were asked whether their child has ever experienced difficulties attending school (response options: 'currently', 'in the past', 'never', or 'not applicable as child never attended a school setting'), and if so, what age their difficulties began. Where attendance difficulties were current, parents were asked how long they had been ongoing, and how many days their CYP had attended school over the proceeding 20 school days. Attendance rates for the current (2021/22) and previous academic year (2020/21; excluding Covid-19-related absences) were also estimated. All parents of CYP with school attendance problems were asked to describe these difficulties using one of the following options: "Self-corrective school avoidance (i.e., absenteeism that remits spontaneously within 2 weeks)"; "Acute school avoidance (i.e., absenteeism that lasts from 2 weeks to 1 year)"; "Chronic school avoidance (i.e., absenteeism that lasts longer than 1 year)"; "None of the above. It looks more like...(please describe)." In addition, all parents were asked about the impact of attending school on their child's MH [response options: 'Extremely positively' (+3), 'Very positively' (+2), 'Somewhat positively' (+1), 'Neither positively nor negatively' (0), 'Somewhat negatively' (−1), 'Very negatively' (−2), 'Extremely negatively' (−3)]. Detailed results will be presented elsewhere, however this measure will be used here as a marker of School Distress severity. Finally, parents were also asked whether the CYP's siblings have a history of school attendance problems.

(3) Educational information: Parents were asked to indicate the types of educational provision their child currently (and if relevant, previously) attended, the total number of schools their child had attended, and whether their child was currently receiving SEN support at school [response options: 'receives no additional support', 'receives SEN support (e.g., is on the SEN register)', or 'has an EHCP/Statement/CSP/ALN (or similar) in place or in process'].

(4) Child health and neurodivergencies: To better understand the needs of CYP struggling to attend school, parents were asked if their child has any physical or MH difficulties (and, if so, what they were), and if they are neurodivergent. Parents who stated their child was (or might be) neurodivergent were provided with a list of possible neurodivergencies (see Table 2 ) and asked to select all that apply to their child (response options: 'has a clinical diagnosis', 'is on the diagnostic pathway', 'had a referral refused', 'suspected but has never been referred and/or diagnosed'). Unless otherwise indicated, prevalence rates for each neurodivergent condition were calculated by accepting endorsement of any of these four options.

Table 2

Neurodivergence

Current SD

Past SD

No SD

Lifelong EHE

Between-group analysis

Mean Number of NDs (StDev)

3.7 (2.5)

3 (2.5)

0.72 (1.7)

2.5 (2.0)

F(3,1,085) = 61.0, p < 0.001

Parents who identified their CYP to have sensory processing disorder were presented with the eight sensory systems (visual, auditory, tactile, olfactory, gustation, vestibular, proprioceptive, and interoceptive) and asked to identify those in which their CYP experienced difficulties. Parents who selected intellectual disability were asked if this was best described as 'mild-moderate', 'severe', or 'profound'. To gain a wider understanding of the CYP's family history, we asked whether either of the CYP's parents, or their siblings, are neurodivergent. Rates of parental neurodivergence will be published elsewhere.

All parents were asked to complete the 24-item Anxiety Scale for Children-Autism Spectrum Disorder-Parent Version (ASC-ASD-P) ( 67), which was derived from a well-validated measure used with typically-developing children ( 68) and developed for use with autistic CYP. The ASC-ASD-P was selected given the anticipated rates of autistic CYP in our sample. This parent-report measure provides a total anxiety score, and individual scores for Separation Anxiety, Uncertainty, Performance Anxiety, and Anxious Arousal (total anxiety will be presented here, and findings regarding specific subscales will be reported elsewhere). Parents respond along a 4-point Likert scale (0 = Never, 1 = Sometimes, 2 = Often, 3 = Always), and Finally, we explored scores are calculated by summing responses, with higher scores indicating greater levels of anxiety (range 0-72). A total score of 20-23 suggests "significant anxious symptomatology," and scores above 24 suggest a "more specific indication of significant anxiety" ( 67). The ASC-ASD-P has excellent internal consistency (α = 0.94) and good convergent validity.

(5) Demand avoidance: All parents were asked to complete the 8-item Extreme Demand Avoidance-8 Caregiver Report Questionnaire (EDA-8) ( 69), which is a refined version of the Extreme Demand Avoidance Questionnaire (EDA-Q) ( 70). The scale's items cover features consistently described in accounts of EDA: obsessive avoidance of demands and requests, outrageous or shocking behavior to avoid, need for control, poor awareness of hierarchy, and lability of mood. The EDA-8 has good internal consistency ( α = 0.90) and convergent and divergent validity, and is proposed to be a useful tool to identify children showing an extreme response to demands ( 69). Parents respond along a 4-point Likert scale (0 = Not at all true, 1 = Somewhat true, 2 = Mostly true 3 = Very true). Scores are calculated by summing responses, with higher scores indicating greater EDA. Cut-off scores are not currently available.

2.5. Procedure

Data was collected using Qualtrics. The survey link was shared widely on social media, and the additional control participants recruited via prolific.org were directed to the Qualtrics link. The original advertisement for the study was posted on Facebook. The original post was 'liked' 441 times, had 60,944 Post Impressions, 48,649 Post Reaches, and 3,714 Post Engagements. Organizations that shared the advertisement included parent support groups such as 'Not Fine in School-Public Page-School Attendance Difficulties' (~29,000 members) and 'Define Fine: Parent Peer Support for School Attendance' (~6,200 members; see Supplementary material for more details).Participants read the information sheet and provided consent before beginning the survey. They were informed that they could skip any questions and stop/start at any time. Qualtrics' display-logic function ensured respondents were only asked questions which were relevant to them. Upon completion, participants were presented with a debrief form, including a comprehensive list of support services. The study ran for 14 days (22/02/2022-08/03/2022).

2.6. Data analysis

Participants were designated to one of four groups based upon whether their child had ever experienced difficulties attending school: the response option 'Yes, currently' assigned them to the Current School Distress group, 'Not currently, but they have in the past' to the Past School Distress group, 'No, never' to the No School Distress group, and 'Not applicable as child never attended a school setting' to the Lifelong EHE group.

Quantitative data analyzes were run using IBM SPSS Statistics V26. Descriptive statistics were calculated to summarize participants' responses to each question. Further statistical analyzes were conducted to examine relationships between variables. Before performing statistical analyzes, normality was assessed by plotting results in histograms and conducting Shapiro-Wilk and Kolmogorov-Smirnov tests. When results were not normally distributed, non-parametric methods were used. A significance level of α  = 0.05 was adopted for most analyzes, and a Bonferroni-corrected alpha level was used to correct for multiple comparisons. Odds Ratios (ORs) were calculated as an estimate of effect size. Correlational analyzes were conducted to examine the relationships between variables using Spearman Rho correlations.

As CYP in the Lifelong EHE group were significantly younger than CYP in the other groups [(Current SD=Past SD=No SD) > Elective EHE, p  < 0.001], it was necessary to conduct additional analyzes using more precisely age-matched comparison groups. Hence, for each CYP in the Lifelong EHE group, two age-matched participants were identified from each of the three other groups. The selected CYP from each group were the two CYP closest in age to the corresponding Lifelong EHE CYP. Analyzes were then replicated using this reduced sample, and conclusions specific to the Lifelong EHE group were derived from these results.

Within our study, we measured four key proxy markers of School Distress: duration, age of onset, attendance rates (in the previous 20 school days, 21/22 academic year, 20/21 academic year), and impact of school attendance on MH. Within this paper, we explored correlations between the four proxy markers and several characteristics of our sample (i.e., anxiety, EDA, and the number of sensory systems that CYP experience difficulties in) to see how they related to School Distress severity.

3. Results

3.1. Demographic information

3.1.1. Gender

52.1% of CYP were cisgender boys, 42.5% cisgender girls, and the remaining 5.4% were split between the non-binary, transgender boy, transgender girl, self-describe, and prefer not to say options.

3.1.2. Age

The mean age of the CYP was 11.6 years. There was an overall between-group difference in age [ F(3, 1,106) = 8.548, p < 0.001], driven by the significantly younger age of the Lifelong EHE CYP [(Current SD=Past SD=No SD) > Lifelong EHE]. No differences remained when considering the Lifelong EHE age-matched subgroups [ F(3, 171) = 0.084, p  = 0.969].

3.1.3. Indices of deprivation

IMD Decile data was available for 47% of Current School Distress CYP, 53% of Past School Distress CYP, 59% of No School Distress CYP, and 16% of Lifelong EHE CYP. There were no significant between-group differences in IMD Decile scores [ F(3,533) = 1.413; p  = 0.238].

A one sample t-test compared the mean IMD Decile against the population mean, estimated to be 5.5. The overall mean in our sample was 6.04 (StDev = 2.9), which was significantly higher than the population mean, t(536) = 4.312, p < 0.001, indicating less deprivation. Broken down into groups, the Current (6.16, StDev = 2.82) and No School Distress group means (6.17, StDev = 2.96) were significantly higher than the population mean [Current SD: t(347) = 4.368, p < 0.001, No SD: t(71)=2.127, p < 0.001], while the Past School Distress (5.50, StDev = 3.09) and Lifelong EHE group means (5.50, StDev = 2.65) were not significantly different than the population mean [Past SD: t(72)=0.16, p = 0.987, Lifelong EHE: t(3)=0.000, p  = 1.000].

3.1.4. Birth order

47.3% of Current School Distress CYP were first-born children (26.5% 'eldest' children and 20.8% an 'only' child), relative to 49.9% who were younger siblings (39.2% 'youngest' and 10.7% 'middle' children). When considering CYP who had experience of School Distress and who were either the 'youngest' or a 'middle' child in their family, we found having an older sibling who had also experienced School Distress was common. More specifically, 42.9% of younger siblings in the Current School Distress group, and 46.5% of younger siblings in the Past School Distress group, also had an older sibling/s with a history of School Distress. Similar figures were obtained when 'youngest' children were considered in isolation (see Supplementary Figure S1). For a complete description of demographic information, see Table 1 .

3.2. School attendance difficulties

3.2.1. Age of onset and duration

The mean age of onset of School Distress across both groups was 7.89 years (StDev = 3.37). This was younger in Past School Distress CYP (7.19 years; StDev = 3.21) than Current School Distress CYP (8.07 years; StDev = 3.21). Strikingly, 51.2% of cases of School Distress first occurred at 8 years or younger. The mean duration of School Distress was 3.99 years (StDev = 2.95). This was longer for CYP whose difficulties had now resolved (4.79 years; StDev = 3.12) than for those whose difficulties were still ongoing (3.79 years; StDev = 2.88). Hence, School Distress began significantly earlier in Past School Distress CYP ( p < 0.01), and lasted significantly longer ( p < 0.001), likely because the Current School Distress CYP were still experiencing School Distress. The age of onset of School Distress was significantly younger for autistic CYP than non-autistic CYP, and School Distress was reported as being significantly more enduring for autistic CYP (see Figure 3 ).

Given the timing of this research, with survey completion occurring almost 2 years after the initial Covid-19 school closures began in the United Kingdom, we explored the percentage of School Distress cases that began before and after the Covid-19 pandemic. In most cases, the onset of School Distress preceded Covid-19 related school closures (Current SD: 69.82%; Past SD: 85.15%).

3.2.2. School attendance problems

For 94.32% of CYP, parents indicated their child's school attendance problems were either partially or fully emotionally-based (i.e., SD).

The existing categories for school "refusal" within the literature ( 58) (self-corrective, acute, and chronic) failed to capture a significant proportion of the experiences of CYP in this sample (see Supplementary Table S1; Other), with 37.1% of cases ( n = 320) falling outside of these categories. Examining the Past School Distress group alone, the 'none of the above' category was selected by 54.2% of parents. Parents who selected this option were asked to describe what their child's School Distress looks like. Example responses can be seen in Table 3 , Q1. These descriptions capture the distress element of the lived experience of School Distress, as do the additional quotes with respect to how School Distress presents in their children ( Table 3 , Q2). A full thematic analysis of this data will be described elsewhere.

Table 3

Summary of Question

Example Quotes

Q1. Parental descriptions of their CYP's school attendance difficulties/situation

"Will go but after huge amounts of upset and panic, odd day of refusal followed by managing to go in with difficulty a day or so later"
"We would manage to get him into school but he would beg not to go (heartbreaking) and feel nausea from waking until he got home (which he would not tell anyone)"
"He attended school but was very distressed, would cry, did not want to go, found being at school pretty stressful (meltdowns at the end of the day)"
"We always got him there - but it was hard on many days""Occasional days off but having to carry a kicking screaming child into school everyday"
"We are able to get her into school most days by carrying her...but if she was bigger...she would be missing school"
"Will attend more times than not but frequently late/part of day only and does not go to lessons or if he does will read or do his own writing rather than engaging with curriculum"
"It's lasted 10 years! Coping on and off depending on which environment she was in"
"Sporadic - in response to situations and difficulties at school with particular lessons, teachers or students"
"Extreme withdrawal and a corresponding lack of expression/engagement"

Q2. Parental descriptions of how their CYP's difficulties present

"Wakes me in the night crying about school"
"Sleep disturbance, tummy aches and bed wetting every night prior to school"
"Vomiting and incontinence at home,"
"Panic on way to school"
"Lashing out at myself and car on way to school and on the way home"
"Attempt to run in front of traffic, attempts to eat nuts (nut allergy)"
"Self harm after a difficult school day"
"Attempted suicide due to unmet needs within school"

3.3. Educational information

3.3.1. Type of education setting

Overall, 97% of CYP had previously, or were currently, attending a mainstream school setting (Current SD: 97%, Past SD: 97%, No SD: 99%). Almost all CYP in the No School Distress group were currently attending a mainstream school, while just 58.3% of CYP in the Current School Distress group remained in this setting currently. The current and past educational provisions of CYP with School Distress experience will be described in more detail elsewhere.

CYP in both School Distress groups had attended significantly more school settings than CYP without School Distress [ F(2,1,007) = 12.986, p < 0.001; Current SD > No SD, p < 0.001; Past SD > No SD, p  = 0.009]. More specifically, the average number of schools attended by CYP in the Current School Distress group was 2.36 (StDev = 1.094), relative to 2.22 in the Past School Distress group (StDev = 1.164) and 1.86 in the No School Distress group (StDev = 0.814).

3.3.2. Support at school (SEN/EHCP)

Of the Current School Distress CYP, 32.8% received no support at school, 38.1% were on a SEN register (or equivalent), and 48.5% had an EHCP or were in the process of seeking one. This declined to 32.9% when we removed cases where parental comments indicated an EHCP was not yet in place ( n  = 111). Of those cases, 95 parents indicated they were in the EHCP process [e.g., applying, applied, in the assessment phase, in the draft stage/awaiting a finalized plan, at mediation/appealing...]. Some of the mediation/appeals were taking place following a refusal to assess or to issue an EHCP following assessment, while others were appealing the content of sections B (description of the CYP's SEN), F (provision required to meet needs), and I (specific placement).

Parental dissatisfaction with the support their child is/was receiving from their school and/or local authority (LA) was clear throughout responses. For instance, many described a lack of support in place (e.g., "Very limited support from school"; see Supplementary Table S2, Q1). Even when parents indicated their child was on the school's SEN register or had an EHCP, comments continued to indicate a lack of support for many CYP (e.g., "Is on the SEN register however no further support in school," see Supplementary Table S2, Q2). Application for and implementation of EHCPs was also a particular source of frustration, with comments including: "I'd to self-apply as school delayed and blocked" and "School not following EHCP" (see Supplementary Table S2, Q3).

Occasionally comments reflected a more positive situation (e.g., "My child's school currently provides reasonable adjustments for my daughter's needs ", see Supplementary Table S2, Q4), however this only represented a small proportion of parent voices.

Finally, some parental comments reflected the complexity of providing support (e.g., "He can receive support from a learning base but he is masking in school and does not want others to know he has autism so only accesses the base twice per week for 50 min per time").

3.4. Child health and neurodivergences

3.4.1. Child health

When asked whether their child has any physical or MH difficulties, only 7% of parents in the Current School Distress group responded 'No', compared to 69.8% who stated 'Yes' and 23.3% who stated 'Maybe'. This differed to the other groups, whereby 23.5% of Past School Distress parents, 79.9% of No School Distress parents, and 56% of Lifelong EHE parents responded 'No'. When asked to specify details of these health difficulties, some parents listed neurodevelopmental conditions. As we later gathered detailed information about neurodivergent conditions, we excluded such responses from analysis (e.g., autism, ADHD, PDA, and sensory processing differences).

Table 4 summarizes the remaining responses with respect to the CYPs' mental and physical health difficulties, with anxiety being the most frequently mentioned condition in all groups. Depression, Hypermobility, PTSD/trauma, and Low mood/emotional regulation difficulties were the next most common in the two School Distress groups, with few incidences in the No School Distress and Lifelong EHE groups. Hence, MH as opposed to physical health concerns (except for hypermobility) were the most frequently mentioned health difficulties by parents of children with School Distress experience. This should not be considered an exhaustive list, as some parents did not complete this, and others may not have listed all health concerns.

Table 4

Physical/Mental health difficulty

Current School Distress (n = 731)

Past School Distress (n = 204)

No School Distress (n = 149)

Lifelong EHE (n = 25)

These responses were further subdivided into three categories: CYP whose parents listed MH difficulties only, whose parents listed physical health difficulties only, and whose parents listed both mental and physical health difficulties. Rates of CYP whose parents reported physical health conditions in isolation were relatively low in all groups (see Supplementary Table S3; Figure 4 ). However, having either MH difficulties in isolation, or in combination with physical health difficulties, was strikingly more common in both School Distress groups than in both the No School Distress and Lifelong EHE groups. No formal statistical analyzes were conducted here as more precise data (including anxiety data gathered using a clinical scale) is described below. Co-occurrence between neurodivergent conditions and health difficulties is also discussed further below.

3.4.2. Neurodivergence

Neurodivergent CYP were significantly over-represented among CYP who currently experience, or who have previously experienced, School Distress, with 92.05% of the Current School Distress group rated as neurodivergent by their parents (i.e., "Yes" or "Maybe"), compared to 22.2% of those without School Distress experience. Statistically, Current School Distress CYP were significantly more likely to be neurodivergent than Past School Distress CYP, and Past School Distress CYP were significantly more likely to be neurodivergent than No School Distress CYP (Current SD > Past SD > No SD). Notably, the OR for a CYP to experience School Distress if they are neurodivergent was 32.57 (95% CI 20.903, 50.762). Restricting the criteria of ND to just the CYP whose parents responded "yes" increased this OR to 42.25 [95% CI (24.53, 72.78)].

Lifelong EHE CYP were equally likely to be described as neurodivergent by their parents as CYP in both School Distress groups [(Current SD=Past SD = Lifelong EHE) > No SD, p  < 0.008 (Bonferroni adjusted alpha level)]. The OR for a CYP in the Lifelong EHE group being neurodivergent (considering "yes" and "maybe" responses) relative to a CYP in the No School Distress group was 25.8 (95% CI 7.26, 91.46), suggesting the Lifelong EHE CYP had neurodevelopmental profiles comparable to the CYP in the two School Distress groups.

Co-occurrence between neurodivergent conditions was high, with many CYP having multiple neurodivergent conditions [overall mean = 3.14 (StDev = 2.62); Current SD = 3.70 (StDev = 2.51); Past SD = 3.0 (StDev = 2.54), No SD = 0.72 (StDev = 1.73); Lifelong EHE = 2.52 (StDev = 2.0)]. Number of neurodivergent conditions per CYP differed significantly between the four groups [H(2)=218.123, p < 0.001], with No School Distress CYP having significantly fewer neurodivergent conditions than all three other groups (all p-values<0.001). No significant differences were found between the Lifelong EHE group and either School Distress group.

Co-occurrence between neurodivergent conditions and health difficulties, particularly MH difficulties, was also high. Notably, 89.14% of CYP in the Current School Distress group whose parents listed one or more health difficulty, were also neurodivergent. Having a physical health condition in isolation accounted for only 0.88% of cases of Current School Distress CYP, while having a mental health condition in isolation accounted for just 6.13% of cases (see Figure 4 ).

3.4.3. Autism

Autism was the most prevalent neurodivergent condition among CYP with School Distress experience (Current SD: 83.4%; Past SD: 66.2%; see Table 2 ). These prevalence rates include all individuals who were either diagnosed or suspected to be autistic, meaning prevalence rates were lower when analysis included only CYP with a confirmed autism diagnosis (Current SD: 46.9%; Past SD: 42.1%).

Statistically, CYP in both School Distress groups were more likely to be autistic than No School Distress CYP (Current SD > Past SD > No SD; see Table 2 for further details). Notably, the OR of an autistic CYP (suspected or diagnosed) experiencing School Distress (Current or Past) was 37.69 [95% CI (23.22, 61.18)], relative to non-autistic CYP. This increased to 46.61 [95% CI (24.67, 88.07)] when analysis included only autistic CYP with confirmed diagnoses.

Lifelong EHE CYP were also significantly more likely to be autistic than No School Distress CYP (Lifelong EHE > No SD). The odds of a Lifelong EHE CYP having a confirmed autism diagnosis was significantly greater than for No School Distress CYP [OR = 6.44 (95% CI 0.98, 42.46)]. This increased further when non-diagnosed autistic CYP were included [OR = 20.11 (95% CI 5.33, 75.85)].

3.4.4. Sensory processing difficulties

The second most prevalent neurodivergent condition among CYP with School Distress experience was Sensory Processing Disorder/Sensory Integration Disorder (SPD/SID), and again, prevalence differed significantly between groups (see Table 2 ). Visual inspection of Figure 5 (column 2) shows the markedly increased prevalence of SPD/SID in CYP with School Distress (top panel) relative to those without School Distress (bottom panel), across the breadth of neurodivergencies and differing levels of anxiety and demand avoidance (with only a few exceptions). CYP within the Lifelong EHE group were also significantly more likely ( n = 13/25) than CYP without School Distress ( n = 5/50) to have SPD/SID [ χ ²(1) = 14.501, p < 0.001; analysis conducted using the Lifelong EHE CYP and their age-matched No School Distress group]. Moreover, restricting the dataset to only non-autistic CYP, SPD/SID remained significantly more prevalent in CYP with School Distress relative to those without School Distress ( χ ² = 21.627, p < 0.001; see Figure 6 ).

In cases where SPD/SID was indicated, difficulties were reported in an average of 4.8 sensory systems (StDev = 2.1) and having difficulties in just one sensory system was rare, accounting for 3.7% of reported cases. When split by group, the mean number of systems impacted was 4.79 for Current School Distress CYP (StDev = 2.08), 4.96 for Past School Distress CYP (StDev = 2.09), 4.1 for No School Distress CYP (StDev = 2.6) and 4.62 for Lifelong EHE CYP (StDev = 2.53). The tactile system, followed closely by the auditory system (both>80%), were the systems identified most frequently as being impacted (see Supplementary Table S4, upper panel).

Across all CYP (including those for whom SPD/SID was not reported), difficulties were reported in an average of 2.28 (StDev = 2.8) sensory systems [Current SD = 2.72 (StDev = 2.8); Past SD = 2.19 (StDev = 2.8); No SD = 0.27 (StDev = 1.2); Lifelong EHE CYP = 2.61 (StDev = 3)]. A Kruskal-Wallis test indicated the number of systems impacted differed between groups, H(3)=111.340, p < 0.001, with pairwise comparisons revealing: Current School Distress (Mdn = 2) > No School Distress (Mdn = 0), p < 0.001; Past School Distress (Mdn = 0) > No SD, p < 0.001; and Current SD > Past SD, p  = 0.046.

For CYP experiencing School Distress, the number of sensory systems impacted (range: 0-8) correlated significantly with School Distress duration (rs = 0.153, p < 0.001), age of onset of School Distress (rs = −0.214, p < 0.001), and school attendance in the previous 4 weeks (rs = −0.141, p = 0.002), 2021/22 academic year (rs = −0.199, p < 0.001), and 2020/21 academic year (rs = −0.137, p = 0.003). Number of sensory systems impacted also correlated with anxiety (rs = 0.422, p < 0.001), EDA (rs = 0.403, p < 0.001), and the degree of emotional distress associated with school attendance (rs = −0.319, p  < 0.001).

When the dataset was split into autistic and non-autistic but otherwise neurodivergent groups, significant differences in frequency of SPD/SID were observed [ χ ²(1,880) = 25.648, p < 0.001]; with 61.6% of the autistic CYP experiencing SPD/SID relative to only 36.8% of the non-autistic neurodivergent CYP. Moreover, when SPD/SID was indicated, the mean number of sensory systems impacted for autistic CYP (mean = 4.89, StDev = 2.08, Mdn = 5) was significantly greater than for non-autistic neurodivergent CYP (mean = 3.81, StDev = 2.23, Mdn = 0, U = 56871.5, p  < 0.001). Note: the neurotypical group was not included in the former analyzes as the working definition of neurodivergence used in this research recognizes sensory processing differences as part of the spectrum of neurodivergence.

Finally, we explored co-occurring conditions amongst autistic CYP with and without School Distress. We found a significantly higher frequency of SPD/SID in the autistic CYP with School Distress experience [Current and Past School Distress combined] than in the autistic CYP with no School Distress experience ( χ ²(1)=9.692, p= 0.002).

3.4.5. Other neurodivergent conditions

The third most prevalent neurodivergent condition among individuals with School Distress experience was ADHD, followed by dyslexia, dyspraxia, Auditory Processing Disorder (APD), speech difficulties, and giftedness, while intellectual disability and spatial processing disorder were the least prevalent (see Table 2 ). Both SPD/SID (see above) and Tic disorders were reported more frequently in autistic CYP (10.2%) than in non-autistic ND CYP (1.8%; χ ²(1,880) = 8.53, p < 0.001), and there were no instances where a neurodivergent condition was more prevalent in the non-autistic ND group relative to the autistic ND group (see Table 5 ).

Table 5

Autistic

Non-Autistic ND

(n = 769)

(n = 114)

χ ²

df

n

Sig

No SD

Autism

100% (n = 769)

0%

-

-

-

-

3.25% ( n = 25)

Sensory

61.6% (n = 474)

36.8% (n = 42)

25.648

1

880

< 0.001

1.94% ( n = 10)

Visual processing difficulties

10.6% ( n = 81)

6.1% ( n = 7)

2.168

1

880

NS

0%

Tic disorder

10.2% (n = 78)

1.8% (n = 2)

8.530

1

880

< 0.01

6.25% ( n = 5)

Unspecified learning disorder

8.5% (n = 65)

6.1% ( n = 7)

0.727

1

880

NS

1.39% (n = 1)

Intellectual disability

7.4% (n = 57)

3.5% ( n = 4)

2.379

1

880

NS

3.22% ( n = 2)

Other

12% (n = 92)

16.7% ( n = 19)

1.952

1

880

NS

2.6% ( n = 3)

Finally, considering the prevalence of other neurodivergent conditions among non-autistic CYP with and without School Distress, we found a significantly higher frequency of ADHD [ χ ²(1) = 29.617, p < 0.001], APD [ χ ²(1) = 11.579, p = 0.001], dyscalculia ( p = 0.007, Fisher's Exact test), dyslexia [ χ ²(1) = 19.998, p < 0.001], dyspraxia [ χ ²(1) = 11.518, p = 0.001], giftedness [ χ ²(1) = 8.666, p = 0.003], SPD/SID [ χ ² = 21.627, p < 0.001], and 'other' neurodivergent conditions [χ ²(1) = 9.385, p = 0.002] among non-autistic CYP with School Distress relative to non-autistic CYP without School Distress (see Figure 6 ).

3.4.6. Anxiety

Individual total scores on the ASC-ASD-Parent Version ( 67) ranged from 0 to 72. Only 7.5% of Current School Distress CYP did not reach the cut-off indicative of significant anxiety symptomatology (i.e., 20), with 92.5% meeting or exceeding this score (see Figure 7A ). Moreover, 86.7% of Current School Distress CYP scored above 24 and therefore exceeded the more specific cut-off score for significant anxiety, while 53.8% of Current School Distress CYP scored at least twice the initial cut-off (40+).

There were also significant differences in the frequency of CYP scoring above and below the initial cut-off score of 20 between the Current and No School Distress groups, χ ²(1, 771) = 353.661, p < 0.001. The OR of a CYP experiencing School Distress if a CYP scored 20+wwas 44.015 (95% CI 26.773, 72.362). Moreover, both Current and Past SD groups had significantly higher total anxiety scores than the No School Distress and Lifelong EHE groups, with total anxiety scores highest in the Current SD group [Current SD > Past SD > (No SD = Lifelong SD), see Table 6 for full details]. Additional analyzes using the Lifelong EHE age-matched comparison groups are presented in Supplementary Table S5.

Table 6

Measure

Current SD

Past SD

No SD

Lifelong EHE

H(3)

p

Significant group differences*

Median

IQR

Median

IQR

Median

IQR

Median

IQR

ASC-ASD-P Total

41

19

33

20

10

12.75

14.5

20.75

296.9

<0.001

Current SD > Past SD > Lifelong EHE and No SD

EDA-8 Total

13

9

9

10

1

4

7.5

7.75

242.9

<0.001

Current SD > Past SD; Current SD and Past SD and Lifelong EHE > No SD

We also explored whether anxiety scores correlated with our markers of School Distress. Higher anxiety correlated significantly with longer School Distress Duration (rs = 0.150, p < 0.001), more negative impact of school attendance on MH (rs = −0.545, p < 0.001) and lower school attendance in the previous 20 days (rs = −0.41, p = 0.002), and the 2021/22 (rs = −0.199, p < 0.001) and 2020/21 academic years (rs = −0.137, p  < 0.001).

However, when CYP ( n = 951) were re-categorized as a function of broad neurotype [i.e., autistic, non-autistic but otherwise neurodivergent, and neurotypical] as opposed to school attendance difficulties, a significant between-group difference in anxiety was also observed ( H = 260.70, df = 2, p < 0.001). More specifically, anxiety was highest in the autistic group and lowest in the neurotypical group (autistic>non-autistic ND > NT; bonferroni-corrected pairwise comparisons; all p-values <0.001). This presence of significantly higher anxiety among autistic CYP relative to neurotypical and non-autistic neurodivergent CYP, regardless of the presence or absence of School Distress, represents a potential confound when interpreting ASC-ASD-P scores as the significantly higher scores in the School Distress groups could have been driven by the significantly different rates of autistic CYP between the groups (see above for more detail), as high anxiety is well documented among such CYP. Hence, we additionally compared anxiety levels between the Current, Past, and No School Distress groups for each neurotype separately. Importantly, significantly higher anxiety in CYP with School Distress was evident in each neurotype [Autistic Group ( n = 662): H (2)=38.631, p < 0.001, Current SD > Past SD > No SD; Non-Autistic ND Group ( n = 87): H (2)=10.111, p = 0.006, Current SD > No SD; Neurotypical Group (n =182): H (2)=85.174, p < 0.001, Current SD=Past SD > No SD] (see Figure 7B ).

3.5. Demand avoidance

The groups also differed significantly with respect to total demand avoidance (EDA-8) scores [H(3)=242.945, p < 0.001], with total EDA-8 scores highest in the Current SD group and lowest in the No School Distress group (see Table 6 ; Figure 7C ). Additional analyzes using the Lifelong EHE age-matched comparison groups are presented in Supplementary Table S5.

Higher EDA-8 scores correlated significantly with longer School Distress duration (rs = 0.095, p = 0.008), younger age of onset of School Distress (rs = −0.205, p < 0.001), more negative impact of school attendance on MH (rs = −0.101, p = 0.011), and worse school attendance in the previous 20 days (rs = −0.126, p = 0.005) and the 2021/22 academic year (rs = −0.106, p = 0.021). Higher EDA-8 scores also correlated significantly with number of sensory systems impacted (rs = 0.402, p < 0.001), and higher anxiety (rs = 0.483, p  < 0.001).

Re-categorizing the CYP with respect to neurotype instead of school attendance difficulties, a significant between-group difference in demand avoidance was also observed ( H = 49.62, df = 2, p < 0.001), with total EDA-8 scores highest in the autistic group relative to both the non-autistic but otherwise neurodivergent group and the neurotypical group [all p-values <0.001]. Again, this presence of significantly higher demand avoidance among autistic CYP relative to neurotypical and non-autistic neurodivergent CYP, regardless of the presence or absence of School Distress, represents a potential confound when interpreting our findings as the differences could be driven by the unequal proportion of autistic CYP across the School Distress and no School Distress groups. Hence, we additionally compared EDA-8 scores between the Current, Past, and No School Distress groups for each neurotype separately.

Importantly, significant between-group differences persisted in both the Neurotypical and the Autistic groups, whereby autistic CYP in the School Distress groups had significantly higher EDA-8 scores than autistic CYP in the No School Distress group [H(2)=34.317, p < 0.001, Current SD > Past SD > No SD], and neurotypical CYP in the Current School Distress group had significantly higher EDA-8 scores than neurotypical CYP in the No School Distress group [H(2)=59.009, p < 0.001, Current SD > (Past SD=No SD)] ( Figure 7D ).

4. Discussion

This study identified several prevalent characteristics among CYP affected by school attendance problems. In most cases, school attendance problems were underpinned by significant emotional distress associated with school attendance, and parental accounts regarding their child's difficulties were often harrowing. This led us to devise the term 'School Distress' to replace pre-existing terms such as "School Refusal," as this reinforces that for many CYP, the defining feature of their experience is not a "refusal" to attend school, but rather the severe emotional distress experienced when attempting to do so (see Figure 1 ). Additionally, definitions of "School Refusal" often require CYP to be absent from school for a period of time [e.g., ( 71, 72) which specify an absence rate of at least 10-50% in the prior month], thus failing to adequately capture the experiences of many of the CYP described above who experienced School Distress but who continued to attend school despite the emotional distress experienced. Given their unaffected attendance rates, and the prior absence of an adequate typology, these CYP's distress may fall under the radar of educational professionals, particularly in the emergent stages. Hence, we argue the 'School Refusal' label, which captures nothing of the emotional distress suffered by CYP and is deeply unpopular with those with lived-experience of SD ( 13), should no longer be used. Instead, we propose these difficulties are best described as 'School Distress', which is not only person-orientated, but also specifically encompasses CYP who manage to attend school despite their distress.

4.1. Children and young people characteristics

The CYP with School Distress experience were young, with onset of their School Distress commonly occurring within their formative years, and their difficulties were enduring. As hypothesized, School Distress first occurred significantly earlier and was more enduring in autistic CYP than in their non-autistic peers, indicating greater School Distress severity. This replicates and extends previous findings showing that school attendance problems occur significantly earlier in autistic CYP ( 33), and aligns with the findings of Munkhaugen et al. ( 34), whose teacher reports indicated greater severity of attendance problems in autistic pupils.

The majority of CYP experiencing School Distress either currently or previously attended a mainstream provision. Thus, while not restricted to mainstream provisions, it appears School Distress is common in CYP whose educational journey originated in a mainstream setting, posing the question of whether mainstream settings are suitable for all CYP, and if not, which provisions may be more appropriate.

Consistent with the literature, we did not find compelling evidence of differential rates of School Distress among male and female CYP. Notably, 3.3% of parents identified their child as non-binary or transgender, and 1% selected 'self-describe', with these options being more frequently selected by parents of CYP with School Distress experience. Future studies should explore this further to ensure transgender and gender-diverse CYP are being appropriately supported in schools.

Notably, CYP with School Distress were significantly more likely to be neurodivergent than CYP without School Distress, confirming our predictions. This is comparable with Epstein et al. ( 73) who, in a smaller sample, revealed that about 90% of CYP missing school had Special Educational Needs/Disability (SEND) or a health problem. Similarly, 75% of Amundsen et al.'s ( 35) participants experiencing school attendance problems were neurodivergent. Co-occurrence of neurodivergencies was high among CYP with School Distress experience, and a large proportion of the CYP experiencing School Distress were neurodivergent and experienced MH difficulties.

The high rate of MH difficulties in our sample is consistent with previous findings showing high levels of depression, anxiety, and stress in CYP experiencing school-related emotional distress [e.g., ( 45-47)]. They are also consistent with a growing mental health crisis that is reportedly affecting CYP both in the United Kingdom ( 74, 75) and globally ( 76). This includes increases in depressive episodes, serious psychological distress and suicide-related outcomes ( 77, 78), and an almost doubling of school loneliness between 2012 and 2018 ( 79). However, in the current study, neurotypical CYP experiencing School Distress alongside a MH condition accounted for just 6.13% of cases. Thus, exploring MH difficulties alone [e.g., ( 46, 47)] is likely to obscure the wider functional profiles of CYP experiencing School Distress, with our data suggesting such CYP predominantly have multiple neurodivergent conditions alongside MH difficulties. Future research should explore the role of neurodivergence in the emergence and maintenance of School Distress further, while simultaneously exploring other factors which could be driving recent secular changes in child and adolescent MH such as increased exposure to social media ( 80, 81), increased testing in schools ( 82), and/or a societal shift to knowledge-based economies that increasingly links life chances with educational performance ( 83). How these latter factors intersect with both School Distress and neurodivergence are also likely relevant.

Sensory processing difficulties (i.e., SPD/SID) were the second most prevalent neurodivergence among our School Distress samples and were significantly more prevalent in the School Distress groups relative to No School Distress CYP. Additionally, sensory processing difficulties were significantly more prevalent in autistic CYP with School Distress than in autistic CYP in the No School Distress group. Finally, although autistic CYP were significantly more likely to have SPD/SID than non-autistic neurodivergent CYP, over a third of non-autistic neurodivergent CYP were still classified as having SPD/SID. Hence, CYP with SPD/SID, and in particular autistic CYP with SPD/SID, may have a particular vulnerability to School Distress. Given that co-occurring sensory processing difficulties appear to increase risk of School Distress in autistic children, this may offer one potential explanation as to why only some autistic children experience School Distress ( 34).

Interestingly, difficulties were noted in the tactile and auditory systems in 4/5 CYP with SPD/SID. Tactile hypersensitivity and auditory filtering have previously been linked to cognitive inattention and academic under-performance in autistic CYP in mainstream classrooms ( 89), potentially providing insight into why individuals with SPD/SID are at increased risk of School Distress. Relevant also are Howe and Stagg's findings ( 90) that autistic pupils attending mainstream school perceived auditory differences to be most disruptive to their learning, followed by touch, smell, and vision. Furthermore, difficulties in the olfactory system were noted in 2/3 CYP with SPD/SID in our study, resonating with observations that "PE changing room" and "incidental smells such as perfume and cleaning products" are particularly challenging sensory experiences for autistic pupils in school ( 36) (p. 7). Such olfactory processing difficulties, alongside differences in the gustation system (indicated in half of the CYP with SPD/SID reported here), may also explain why many autistic CYP find school halls/canteens particularly distressing. The sensory difficulties identified in this study align with the findings of Jones et al. ( 36) who explored the impact of SPD on autistic pupils' learning and school life, with parental comments including: "They try to protect themselves by covering their ears, closing their eyes, pulling their t-shirts over their noises to block out smells." In order to fully elucidate the role played by SPD in School Distress, future studies should seek to further assess the severity of these difficulties, the specific systems in which they occur, and explore these parameters with respect to anxiety, demand avoidance, autism, and neurodivergent more broadly.

ADHD, APD, dyscalculia, dyslexia, dyspraxia, giftedness, SPD/SID, and 'other' neurodivergent conditions were significantly more prevalent in non-autistic School Distress CYP relative to non-autistic CYP with No School Distress, indicating that these neurodevelopmental differences may increase risk of School Distress in the absence of autism. Given the high co-occurrence of neurodivergent conditions in this study, coupled with autism being so prominent among School Distress CYP, care is however needed when interpreting the individual impact of each neurodivergent condition on School Distress. Interestingly, the high co-occurrence of neurodivergent conditions in our School Distress sample may be a key finding in itself; whereby it may be the complexity of managing multiple neurodivergent conditions within an environment optimized for the neurotypical learner that overwhelms these CYP and renders the school environment so difficult and detrimental to their wellbeing. Support and planning will likely therefore need to be multidimensional and bespoke to the specific needs of individual CYP experiencing School Distress. Future studies may seek to fully explore the prevalence of School Distress in CYP with neurodivergent conditions such as ADHD, dyslexia, and dyspraxia, all of which were present at relatively high rates in our School Distress groups.

The disproportionate rates of neurodivergence found among School Distress samples are extremely concerning and indicate that appropriate support for neurodivergent CYP needs to be improved. Relatedly, care needs to be taken to ensure CYP with School Distress have access to timely assessments of underlying neurodivergent conditions, with autism, SPD/SID, ADHD, dyslexia, dyspraxia, and EDA (among others) all important to consider. It is also critical that educators and policy makers consider whether mainstream schools are truly inclusive environments for CYP with SEND more broadly. Indeed, D'Alessio ( 91) highlighted that SEND CYP are frequently segregated from peers, resulting in feelings of exclusion within mainstream environments, while Webster et al. ( 92) described the experience of high-needs SEND CYP as often equating to " marginalization masquerading as mainstream" (p. 77).

Of additional concern is the finding that over 90% of Current School Distress CYP met or exceeded the cut-off indicative of significant anxiety symptomatology on the ASC-ASD-P. Moreover, CYP in both School Distress groups had significantly higher anxiety than CYP who have never experienced School Distress, regardless of neurotype. When grouped with respect to neurotype and School Distress experience, the autistic Current School Distress group had particularly high anxiety scores (mean = 41.52, which is over twice the cut-off score for significant anxiety). Such scores are markedly higher than previously published scores using the ASC-ASD-P in autistic CYP ( 93). Such elevated scores are of concern, not least because higher anxiety severity is associated with a lower quality of life in both autistic and non-autistic children with anxiety disorders ( 94), and in autistic CYP more generally ( 93, 95). Hence, supporting individual CYP experiencing such levels of anxiety should be a priority for educational and health-care professionals. Overall, while these findings replicate those of Gonzalvez et al. ( 47) who also found significantly higher anxiety levels among school "refusing" CYP compared to CYP without school attendance problems, it also extends previous research by using a larger sample size and a broader typology, and considers CYPs' neurodevelopmental profiles. Moreover, it builds on previous research by using a clinical scale devised using evidence of the anxiety phenomenology in autistic CYP specifically, including items relating to sensory anxiety, intolerance of uncertainty, and phobias ( 67). This is important as anxiety symptoms differ in the context of autism ( 96), and autistic CYP appear to be at considerably greater risk of School Distress. Of note, mean anxiety scores in autistic CYP in the No School Distress and Lifelong EHE groups also exceeded the cut off for significant anxiety, demonstrating the more general heightened anxiety in autistic CYP, however these scores were markedly lower than in the School Distress groups. Finally, when exploring how anxiety related to our proxy markers of School Distress, we found higher anxiety significantly correlated with more extensive School Distress, greater level of emotional distress due to school attendance, and lower school attendance in the previous 20 days, and in the 20/21 and 21/22 academic years. Such high anxiety among CYP with School Distress may be a cause or consequence of School Distress, or both.

As anticipated, School Distress CYP scored significantly higher on the EDA-8 ( 69) than No School Distress CYP. Hence, consistent with parental accounts, CYP with School Distress appear to display significantly more EDA behaviors than CYP who attend school without difficulties. Additionally, scores on the EDA-8 correlated significantly with all proxy markers of School Distress severity and higher anxiety, reinforcing the link between EDA and anxiety, and supporting previous anecdotal and research links between Demand Avoidance and school attendance problems ( 59, 60). Interestingly, autistic CYP had, on average, higher EDA scores compared to both the NT and non-autistic neurodivergent groups, confirming previous accounts linking high levels of demand avoidance to the autistic experience.

In addition to the above correlations, scores on the EDA-8 also correlated with the number of sensory systems in which CYP experience difficulties. These relationships warrant further consideration to understand why and how demand avoidant behaviors become so pervasive in autistic CYP (and indeed in some otherwise neurodivergent and neurotypical CYP), and how they relate to the emergence and maintenance of School Distress. This could help address the current dearth of understanding of how best to support CYP with demand avoidant profiles in traditional education settings, particularly in mainstream school environments that so often fail to provide inclusive sensory environments for CYP who experience considerable sensory distress ( 40).

Strikingly, almost one-third of parents in the Current School Distress group reported that their child received no support at school. Moreover, for many of those CYP who were on the school's SEN register (or equivalent) or had an EHCP, this did not translate into ring-fenced SEN support at school, as indicated by parental comments, with many parents also referring to a lack of support from their child's school when they attempted to seek additional support, and schools blocking their attempts to secure an EHCP for their child. The likely reason for this is well documented elsewhere, i.e., the issues of school budgets and the fact that English schools must pay the first £6,000 of meeting an EHCP from their own budgets annually ( 97, 98).

4.2. Birth order and sibling school attendance problems

Within this study, we replicated a previous observation in the literature which noted that a high rate of CYP who experience school attendance problems are the youngest child in their family ( 99). This was particularly evident in our Current School Distress group, where almost 40% of CYP were the youngest in their families. Given that we also found that youngest CYP with School Distress often had an older sibling(s) who had also experienced attendance problems ( Supplementary Figure S1), the high rates of youngest children experiencing School Distress observed here may well be due to multiplier effects, whereby genetic (e.g., ND) and environmental factors (e.g., experience of a previous sibling's School Distress, specific SEND provision in the local schools) interact and compound the risk of subsequent children in the family experiencing School Distress.

4.3. Lifelong EHE CYP and their families

CYP whose parents had decided school-based education was not appropriate for them at an early point in life (Lifelong EHE) showed similar neurodevelopmental profiles to School Distress CYP, with comparable rates of neurodivergence. Lifelong EHE CYP were also significantly more likely to have both sensory processing difficulties and elevated demand avoidant scores relative to No School Distress CYP. Importantly, however, there were no significant differences with respect to anxiety scores between the Lifelong EHE CYP and the No School Distress CYP, and both of these groups had significantly lower anxiety scores than the Past and Current School Distress groups, indicating that despite comparable neurodivergence and demand avoidant profiles in the Lifelong EHE CYP, these young people were not experiencing the same levels of anxiety as the CYP who experienced School Distress (be that currently or historically). Relatedly, while 92.2% of Current School Distress and 84.5% of Past School Distress CYP met the clinical cut-off indicative of significant anxiety on the ASC-ASD-P, only 40% of Lifelong EHE CYP met this score. Hence, Lifelong EHE CYP, and particularly neurodivergent Lifelong EHE CYP, are an important comparison group here, and suggest that neurodivergent profile alone is not sufficient to account for these markedly different anxiety profiles. Future research should attempt to explore the emergence of anxiety in both school and home educated ND/demand avoidant CYP longitudinally, to more fully understand the drivers of this anxiety.

Additionally, some of the parents of Lifelong EHE CYP explicitly stated that their child's neurodevelopmental profile was a key determinant in their decision not to enrol their child in a school setting. These parents noted recognizing early in their child's life that, given their child's neurodivergent profile, they would likely face difficulties accessing school-based education (see Supplementary Table S2, Q5). Moreover, some reported that they considered EHE a better fit to their child's needs as it affords them flexibility to readily adapt their approach to meet the child's individual learning needs (see Supplementary Table S2, Q6), or to provide the levels of individual support required (see Supplementary Table S2, Q7). This flexibility attunes with the advice of specialist PDA educators ( 62). However, home education is simply not a feasible educational option for many families, not least due to the considerable financial implications. Moreover, on a societal level, is it acceptable for education outside of the family to be inaccessible to some CYP, simply as a consequence of their neurodivergent profile?

4.4. Limitations

One key limitation is the lack of diversity among our sample, with an over-representation of white CYP, meaning our findings may not accurately represent the profiles of all CYP experiencing School Distress. Our Current and No School Distress groups were also living in less deprived areas than would be expected by chance alone. Thus, future research should aim to collect more diverse samples to gain a more comprehensive understanding of the experience of School Distress across all CYP, and to therefore guide more individualized support. Such research may identify different drivers of school attendance problems.

Moreover, this study was limited to the United Kingdom, further reducing the generalisability of our findings. As education systems vary internationally, the School Distress experience and the characteristics of individuals experiencing School Distress may differ between countries, providing an additional avenue for future research.

Additionally, while this study was advertised widely on social media (with a considerable number of post impressions, reaches and engagements), the sites where it was shared may have influenced who participated. For example, within our No School Distress group, 16.8% of CYP were autistic, despite the national prevalence rates of autism standing at around 1-2% ( 100), indicating this group may not be entirely representative of all CYP who do not experience School Distress. The advertisement was however shared on the largest family support page for families of children and young people facing barriers to school attendance (for whatever reason) in the United Kingdom, i.e., Not Fine in School. Future studies should formally record the social media site that each respondent comes from.

Alternative recruitment strategies include sampling directly from schools, e.g., by contacting parents whose children have a greater number of absences. However, whilst such an approach may confer certain advantages, it would miss the CYP who have fallen out of the school system ( 101), and hence may only capture milder, or emergent, forms of School Distress. As the data presented here indicates that School Distress is more enduring and associated with higher levels of anxiety and demand avoidance in autistic CYP, sampling milder presentations would likely result in autistic CYP being underestimated. Sampling via schools would likely also miss the CYP who, despite experiencing considerable School Distress, manage to maintain attendance at school, as these CYP may fall under the radar of educational professionals. Moreover, school attendance problems may be the first indicator to professionals that a CYP is not managing in their environment, and it may take some time before the underlying driver of this is identified (e.g., autism, ADHD, dyslexia, etc.), resulting in some emergent cases of School Distress initially being mis-attributed solely to MH difficulties. Indeed, a recent meta-analysis indicated that only 72.4% of cases of autism and 56.8% of cases of ADHD have been recognized by age 14; figures that rise to 89.8% by age 18 and 94.8% by age 25 for autism, and 73% by age 18 and 91.8% by age 25 for ADHD ( 102).

Online recruitment via social media also enabled us to attempt to capture the full age range of CYP attending United Kingdom schools. While this is a likely strength of the study, it needs to be noted that the age range of the specific sample will likely influence the characteristics. Hence these findings may not extrapolate fully to a more specific age range and, in particular, to mid to late adolescents. This is because, firstly, the overall peak age of onset of mental health difficulties does not occur until 14.5 years of age (and the mean age of the CYP in the current study was just 11.6 years of age), and secondly, because the peak age of onset of MH difficulties varies considerably depending on MH subtype [e.g., 5.5 years of age for anxiety/fear-related disorders relative to 20.5 years of age for mood disorders ( 102)]. In addition, environmental factors that appear to place downward pressure on CYPs' MH, such as social media use ( 81), vary depending on age, with current estimates indicating that 33% of 5-7-year-olds relative to 97% of 16-17-year-olds use social media ( 103). Moreover, there appear to be distinct developmental windows of sensitivity to social media in adolescence, i.e., 11-13 and 19 years old for females and 14-15 and 19 years old for males ( 80). Hence, both age and sex of the cohort sampled may impact the observed characteristics.

Notably, we used a broad criterion for neurodivergent conditions, including CYP currently awaiting assessment/diagnosis, CYP whose referral was rejected, and CYP who have yet to be referred. The rationale behind this is discussed at length above, however it is possible this led to an overestimation of prevalence rates. A final weakness of this study is the differing sample sizes between participant groups, with the Lifelong EHE group being particularly small, potentially influencing the accuracy of between-group comparisons. Future research should collect more evenly sized participant groups, although this is challenging in rarer groups such as Lifelong EHE CYP. This disparity did, however, arise due to the volume of CYP currently experiencing School Distress in the United Kingdom.

One key drawback of the School Distress literature generally, as opposed to this study specifically, is the lack of a standardized questionnaire to assess School Distress which is suitable for use in autistic individuals. Given the prevalence of autism among CYP experiencing School Distress, development of such a questionnaire which can be used in clinical, education, and research settings is vital. Thus, one next step should be to gather perspectives of autistic CYP and autistic adults, and to work collaboratively with them to develop a standardized questionnaire to assess School Distress severity and/or risk.

This study also had several strengths, including the large sample of CYP currently experiencing School Distress, and the exploration of various aspects of School Distress within this large sample size. This was much greater than in previous research, enabling stronger conclusions to be made.

5. Conclusion

The Human Rights Act states "No person shall be denied a right to an education" ( 104). However, our findings suggest that a large number of CYP are being denied access to education due to the emotional distress they experience at school. The finding that particular groups of individuals with a recognized disability (e.g., autistic CYP) are specifically affected is of grave concern, particularly when one considers the Human Rights Act ( 104), the Equality Act ( 105), the Children Act ( 106), and Articles 23 and 28 of the United Nations Convention on the Rights of a Child ( 107), which enshrine all CYPs' right to an education regardless of disability.

Further research involving both autistic and non-autistic CYP who experience School Distress, and their families, is urgently needed to further understand this problem, and develop solutions that ensure all CYP can access education, and that all families have the option to avail of safe educational opportunities for their child outside of the family. Such research should be used to inform future changes to education legislation, as legislation changes which do not consider this evidence-base run the risk of making the current situation even worse for those CYP at risk of distress-based school attendance difficulties.

Wider discussion with respect to the appropriateness of traditional, school-based education for all CYP is needed. Further research, ideally co-produced with autistic and otherwise neurodivergent individuals, is needed to determine best practices in education, and to ensure appropriate understanding of how neurodivergent pupils best learn ( 58). Relatedly, research into best-pedagogical practice for pupils with SEND, including pupils with complex presentations, is urgently needed, especially within mainstream settings ( 108). Given the substantial heterogeneity in the neurobiology of autism, this will undoubtedly be complex, and efforts must include consideration of how learning needs will vary with neurosubtype ( 109, 110) and demand avoidant profile ( 57). Research exploring educational and life outcomes of Lifelong EHE CYP, and CYP with provisions such as EOTAS, is also urgently required to better understand how CYP can be successfully educated outside of school settings.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

SM and SC conceptualized and designed the study, organized the database, and performed the initial statistical analysis. SC, HC, and SM performed the final statistical analyzes. SC and SM wrote the initial drafts of the manuscript. All authors contributed to the article and approved the submitted version.

Acknowledgments

We sincerely thank all the parents who generously gave up their time to take part in this research. We wish them, and their children, all the very best in the future. We also thank Katherine Patterson and Eliza Hockey for their assistance with initial data processing and analysis, Kieran Rose ( https://theautisticadvocate.com/) for his advice on language, Ellie Costello ( https://www.teamsquarepeg.org/) for her assistance with distribution of the questionnaire and discussions around barriers to school attendance more broadly, and Eliza Fricker ( https://missingthemark.blog/) for permitting the use of her illustrations in Figure 1 .

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

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by Lorna G. Hamilton

Lorna G Hamilton is Associate Professor of Developmental Psychology at York St John University. Her [...]

School of Education, Language and Psychology, York St John University, York, YO31 7EX, UK

1. Introduction

The return to "school as normal" following seismic disruption to education during the peak of the COVID-19 pandemic in 2020-2021 posed challenges for pupils, teachers and school leaders in many countries. In the English post-pandemic context, education leaders have expressed concern about substantially increased levels of anxiety and school absence among pupils of all ages [ 1, 2]. Data published by the Department for Education indicate that levels of "persistent absence" (i.e., >10% missed lessons) in the 2022-2023 academic year were more than double the pre-pandemic figures [ 3]. While the reasons for this rise are complex and multifactorial, there is increasing recognition that persistent absences are often underpinned by emotionally based school avoidance (EBSA), in other words, significant and chronic anxiety associated with the school environment that triggers avoidant behaviour [ 4, 5]. This terminology is preferred to "school refusal", which implies a level of wilfulness or choice on the part of the child. EBSA, by contrast, recognises that for many children, persistent absence from school is rooted in emotional and mental health issues [ 6]. However, it is important to acknowledge that, for some pupils, these emotional issues are directly related to stressors in the school environment.

In this article, the association between mental health and school attendance in the post-COVID-19 context is considered, drawing on research with autistic pupils in mainstream school settings in England as an illustrative example. Issues of belonging, agency and power in schools are discussed, in order to contextualise a critical review of different approaches to reducing persistent school absence.

2. School Attendance and Pupil Mental Health in England

The Children's Act (2004) established for the first time the position of Children's Commissioner for England, with responsibility for protecting the rights of children in line with the United Nations Convention on the Rights of the Child. Since 2020, school attendance has been a key priority for the Office of the Children's Commissioner, given the established links between absence from school and a range of negative outcomes [ 7]. Missing children, missing grades, a recent report produced by this office, highlights that since the period of intermittent school closures during lockdowns in response to the COVID-19 pandemic, "school absence rates have been stuck at crisis levels" [ 8] (p. 4). The report presents confirmatory evidence of an association between pupil attendance and attainment at GSCE (General Secondary Certificate of Education, the national qualifications undertaken at the end of compulsory secondary education in England, typically at age 16). Concerningly, this association is strongest in pupils accessing free school meals (an indicator of family socio-economic status) and in those identified with a special educational need (SEN), presenting a significant barrier to equality of educational opportunity [ 9]). While the report does not include an in-depth analysis of the factors underpinning increased pupil absence since the pandemic, the breakdown of the "social contract" between schools and families and the inconsistent availability of mental health support in schools are highlighted as targets for intervention. Comparable concerns about increased pupil absence post-pandemic have been raised in other countries (e.g., [ 10, 11]).

There is evidence that mental health need among children and young people was rising in England before the outbreak of COVID-19. Prevalence data from the first decade of the century yielded estimates of around one in ten young people experiencing clinically significant mental health problems (e.g., [ 12]). In contrast, studies from the second decade of the century typically report substantially higher prevalence estimates. For example, Fink et al. (2015) [ 13] reported overall stability in mental health difficulties as captured by the Strengths and Difficulties Questionnaire (SDQ) [ 14] in cross-sectional samples of 11- to 13-year-old adolescents, between 2009 and 2014. However, emotional problems in girls increased markedly during this time period (from 13.1% in 2009 to 20.3% in 2014). Deighton et al. (2019) [ 15] report probable mental health difficulties within a community sample of over 28,000 English adolescents aged 11 to 14 years also using the SDQ. Over 40% of young people scored above the 'abnormal' threshold for one or more of emotional symptoms (18.5%), conduct problems (18.5%) and/or inattention/hyperactivity (25.3%). Having an identified SEN or being eligible for free school meals increased the likelihood of experiencing a mental health challenge. In a sample of 6000 children from the north of England collected in 2017/18, the same measure yielded 'high/very high' emotional symptoms in 22% of respondents, conduct problems in 9% and inattention/hyperactivity in 18% [ 16], with girls and older pupils reporting higher levels of difficulty. The reasons for this apparent trend of increasing mental health need in English children and young people through the decade preceding the COVID-19 pandemic can only be speculated but may include greater awareness of mental health issues among young people, societal and economic pressures following the global recession of 2008, and reduced access to mental health services during a period of austerity in economic policy [ 17]. Importantly, having mental health difficulties at the start of secondary education at age 11 predicted persistent absence from school in a large sample of English pupils in 2017, after controlling children's SEN status and family socio-economic status [ 18].

The influence of school-level factors on this trajectory of increasing mental health need among pupils is largely unascertained. Negative experiences in school, such as academic failure and bullying, are well known to relate to poor mental health, although the direction of effects is complex and dynamic [ 19, 20]). Leurent et al. (2021) [ 21] report a longitudinal analysis of school climate and pupil mental health in a sample of over 3000 adolescents in south-east England. School climates that foster belonging (as rated by pupils) predicted better mental health outcomes three years later; however, this association was substantially attenuated when pupils' mental health at baseline was controlled, limiting causal interpretation. Pupil-rated negative school climate is also associated with chronic absence rates [ 22]. Critics of educational policy in England in recent years have argued that a narrowed national curriculum, with reduced time and funding available for creative and technical subjects and a culture of high-stakes testing, has negatively impacted wellbeing at schools for many pupils [ 23, 24]. Concerningly, in a large mixed-methods study conducted between 2020 and 2022, a high proportion of English secondary pupils reported that school was neither enjoyable nor meaningful for them [ 25]. Many found the recent sharpened focus on traditional academic subjects, limited choice in pursuing subjects of individual interest and prioritisation of attainment in exams to be alienating, stressful and deleterious for mental health.

In England, schools were closed to all but the most vulnerable pupils as a containment measure during the peak of the COVID-19 pandemic between March and September 2020, reopening for cohorts in key assessment years in June 2020. A second period of school closures followed in response to a further wave of infections between January and March 2021. Through this period, the Co-Space study tracked the mental health of a large sample of children and young people, finding that hyperactivity and conduct problems increased during the first lockdown, while emotional symptoms remained relatively stable [ 31]. Over a fifteen-month period from the start of the first lockdown, the majority of participants followed stable trajectories of low or moderate mental health difficulties; however, a smaller group showed very high/high stable or increasing trajectories [ 32]. Qualitative findings suggest that young people reported an enduring sense of unease during periods of lockdown, tending to ruminate, worry about the future and express concerns both about the loss of time at school and their safety when attending school in person [ 33].

At the same time, periods of lockdown offered a respite for those young people who had previously experienced difficulties at school, facilitating improved mental health in this subgroup. For example, in a sample of nearly 17,000 children and young people from four counties in southern England surveyed towards the end of the first period of school closures in 2020, approximately a third reported improvements to their wellbeing through lockdown [ 34]. For these pupils, enforced removal from the school environment led to decreased loneliness and feelings of being left out, reduced experiences of bullying, better management of academic tasks, improved sleep, more exercise and enhanced relationships with family members and close friends. Similar insights have been reported in qualitative studies using diary methods to sample young people's experiences through lockdown [ 35, 36]. For some young people, school closures meant reduced stress and an increased sense of autonomy in their daily lives. Further, children with pre-existing mental health needs may have learned that staying away from school relieved chronic feelings of anxiety [ 37].

3. Autistic Pupils in Mainstream Schooling

Autistic pupils constitute one disadvantaged group within the school system. Over 70% of autistic children are educated in mainstream settings in the UK, and schools have a statutory duty to make reasonable adjustments for neurodivergent differences under the Equality Act (2010). However, educational experiences and outcomes are known to be poorer for autistic children than for their non-autistic peers [ 40]. Fewer than half of autistic pupils in the UK report being happy in school, with many identifying an improved understanding of autism within their school community as the factor that would make the most difference to their feelings about school [ 41]. At the same time, training for teachers and school staff on autism and neurodiversity is inconsistent and often minimal; many teachers report that they do not feel confident supporting autistic learners [ 41]).

Levels of absence from school, both due to exclusion and EBSA, are notably high among autistic pupils [ 42]. Over 30% of autistic pupils in England are identified as "persistent absentees", incorporating both exclusion from school and EBSA [ 3, 43]. In a recent study, 947 parents of children experiencing school distress were surveyed alongside an age-matched control group [ 44]. Nearly all respondents reported that their child's attendance difficulties were underpinned by significant psychological distress, and 92% of those experiencing school distress were identified as neurodivergent. Autistic children in particular were reported as exhibiting school-related distress with an earlier onset and longer duration than other groups of pupils. There is evidence that autistic girls are especially likely to experience EBSA in comparison with boys [ 45, 46]. There is thus an urgent need to better understand barriers to school attendance in this population in order to develop targeted supports.

Negative educational outcomes are often underpinned by a poor fit between school environments and autistic ways of being in the world. Contributory factors include social and sensory barriers, but also systems and policies that can penalise neurodivergent behaviours with the result that school is not always experienced as a safe place [ 45, 47]. Numerous studies have shown that autistic children face a high risk of bullying from peers, which often endures for many years [ 48, 49, 50]. Many autistic children are highly aware of their differences, and liable to blame themselves for unsuccessful interactions with peers at school [ 51, 52]. Cumulative negative social experiences contribute to the tendency to mask autistic traits (or 'socially camouflage'), which is increasingly recognised as a driver of identity confusion and poor mental health in autistic young people [ 53, 54].

The physical school environment can be aversive for autistic sensory processing differences, particularly in large, busy secondary school contexts [ 55, 56]. Self-management of sensory stress (e.g., avoiding the busiest corridors, adjusting an uncomfortable school uniform) can take up cognitive and emotional resources and detract from classroom learning [ 47, 56]. Additional stressors that can be particularly salient for autistic pupils include managing unstructured time at break periods, negotiating transitions and understanding and applying school rules [ 57]. This array of everyday challenges faced by autistic pupils sits against the backdrop of structural issues within the Special Educational Needs and Disability (SEND) system that can lead to delays in children receiving statutory in-school support [ 58].

During the height of the COVID-19 pandemic, parent-report surveys indicated high levels of depression and anxiety in autistic children in comparison with neurotypical peers, which were largely maintained through the year of intermittent lockdowns [ 59, 60]. However, for a minority, parents reported that removal from the daily pressures of the school environment led to improvements in mental wellbeing [ 61]. For this subgroup, the transition back to school may have been especially difficult to navigate, fuelling school avoidance. In a large survey of parents of 5- to 14-year-old children with intellectual disability and/or autism conducted in 2021, child anxiety predicted both overall levels of absenteeism and the number of days of school avoidance. Conversely, positive home-school relationships negatively predicted absence from school [ 62].

Qualitative work that foregrounds the voices of neurodivergent children and young people is still relatively rare [ 63]. A longitudinal study foregrounding autistic pupils' first-person perspectives on their experiences in mainstream school in the north of England from age 11 to 14 included a final data collection point during intermittent lockdowns in 2020-2021 [ 47, 64]. Some children learned at home throughout this period, while others held a priority school place during the second period of school closures. Several children expressed worry about the transmission of the virus, and families experienced heightened stress within the home as they negotiated home learning alongside work and financial pressures. However, for those who had reported chronic bullying at school during earlier phases of the study, lockdowns were experienced as a relief, and parents reported that their mental health improved. Moreover, some pupils relished the opportunity to pursue interest-led learning from home (e.g., studying a new language), although this could come at the expense of following the school curriculum. On the return to school in 2021, small class "bubbles" designed to limit viral transmission also reduced the social and sensory chaos of the school environment [ 64]. For these children, the disruption of the pandemic gave an insight into alternative ways of learning, and the return to school as normal in 2021-2022 is likely to have been particularly challenging.

4. Belonging and Agency in School

Of course, not all of the Children's Commissioner's "missing children" are missing due to EBSA, nor are all children experiencing EBSA autistic. However, it may be argued that many are "neurodivergent", broadly defined, in terms of mental health need and/or neurodevelopmental differences such as ADHD or specific learning difficulties [ 65]. Perhaps more helpful than targeting intervention towards specific diagnostic categories would be building a holistic understanding of the factors that lead a minority of children to perceive school as a hostile environment. Ideally, this understanding would inform universal design approaches to modifying school environments for the benefit of all pupils. Here, two psychological factors that are common to many individual cases of persistent absence from school are considered: (lack of) belonging and agency.

Psychological theories of human motivation have long identified the importance of a sense of belonging, or connectedness within a group [ 66, 67]. A subjective sense of belonging comes from an individual's perception of the quality of, and satisfaction with, social connections, but does not depend on levels of participation in social interactions. The belongingness hypothesis [ 68] predicts that an individual's subjective sense of belonging facilitates goal-directed activity and is protective of both mental and physical health. Some psychological accounts have posited that autistic people lack the motivation to form connections with others (e.g., the 'social motivation hypothesis' [ 69]). However, this account has been widely critiqued for its assumption that behaviour can be interpreted as a simple indicator of motivation [ 70] and its failure to integrate first-person autistic perspectives [ 71]. Multiple studies and lived experience accounts show that belonging and social connection are important motivators for autistic people, although societal stigma and neuro-normative expectations of social interaction can act as significant barriers to belonging [ 72, 73].

School belonging is defined by Goodenow and Grady [ 74] (pp. 60-61) as "the extent to which students feel personally accepted, respected, included, and supported by others in the school social environment" and is a predictor of academic attainment and wellbeing for children and young people [ 75]. School belonging is more difficult to attain for minority groups within the school environment. Research suggests that autistic pupils in mainstream settings are motivated to form a sense of belonging in school [ 76, 77]. Nonetheless, school connectedness tends to be lower in autistic students than in their neuro-majority peers [ 78], and they are more likely to experience loneliness and isolation in school [ 79]. The prevalence of bullying towards autistic children is a significant barrier to school belonging [ 80]. In order to fit in with peers at school, autistic pupils-and especially girls-report feeling pressure to minimise their differences and adapt behaviour to accord with neuro-normative expectations [ 45, 77]. Such masking behaviour is emotionally costly and can lead to burnout and behavioural challenges at home [ 52, 81]. Interventions that facilitate authentic belonging for autistic and neurodivergent pupils and reduce the imperative to mask differences are plausible mechanisms for addressing EBSA.

However, behaviourist principles of reward and punishment are often preferred over participatory, collaborative approaches to tackling the problem of school absence. The practice of rewarding perfect pupil attendance records through prizes or other forms of recognition is widespread in schools in England and elsewhere, despite research suggesting that this approach is not effective in reducing school absence [ 87, 88]. Attendance award schemes have been critiqued for their assumption that all pupils have the capacity to attend school every day, thereby rewarding the sheer luck of good health [ 89]. Where physical illness or disability means that children have to spend time in hospitals, clinics or recovering at home, they see a behaviour rewarded in their peers that is unattainable for them and over which they have no agency. Many lived experience accounts from neurodivergent pupils and their parents describe non-attendance at school in similar terms; it is not a choice to stay away from school, but a necessity in response to intense and debilitating anxiety elicited in the school environment (e.g., [ 90]). Zero-tolerance behaviour policies, which take little account of the underlying reasons for challenging behaviours, can be similarly critiqued for perpetuating stigma against already marginalised pupil groups [ 91]. Moreover, some light-touch whole-school approaches to intervening for pupil mental health, when implemented universally without consultation with young people, can even be harmful [ 92, 93]. For example, a universal school-based intervention programme drawing on dialectal behaviour therapy did not improve social and emotional symptoms in adolescents; indeed, deteriorations in depression and anxiety symptoms were recorded immediately post-intervention compared with school-as-usual [ 94].

In order to meaningfully address EBSA, approaches to intervention that promote school belonging and give young people agency in co-creating solutions are needed. In the next section, some approaches that show promise in this regard are reviewed.

5. Addressing Emotionally Based School Avoidance with Young People

The need for further research to understand how best to support children experiencing EBSA in returning to school is pressing. A recent rapid review of the evidence on interventions for school attendance identified 72 relevant studies, almost all of which were conducted in the US context and all pre-pandemic [ 95]. Overall, the quality of the evidence was evaluated as weak, with a high risk of bias. A wide variety of strategies to reduce school absence was employed across studies; of eight themes identified, the most promising were engagement with parents and responsive, targeted approaches designed according to children's individual circumstances and needs [ 95, 96]. Conversely, there was little evidence to support the effectiveness of behaviour interventions or approaches based on (dis)incentives.

Here it is proposed that increasing belonging in school among pupils, especially those in marginalised groups, is a primary mechanism through which EBSA can be reduced [ 97]. Relatedly, giving pupils a sense of agency by involving them in decisions that affect their lives at school is likely to increase belonging. Interventions that target school belonging and promote agency are therefore indicated.

Multi-tiered systems of support (MTSS) approaches to intervention are proactive and-as far as possible-evidence-based. When applied to addressing EBSA, a multi-tiered systems of support approach would aim to identify and support children at risk before absence from school becomes entrenched [ 7]. At Tier 1, universal, whole-school strategies are implemented to build a positive school culture and facilitate a sense of psychological safety and belonging at school for all pupils. Targeted interventions are designed for those pupils who do not respond to these primary strategies (Tier 2). For pupils with the most complex needs for whom Tier 2 strategies are not sufficient, intensive individualised interventions are introduced (Tier 3). The identification and implementation of interventions at each tier will vary across school contexts in order to align with community values, resources and priorities for action. However, some common principles may be applicable even in the context of resource and staffing constraints in schools.

Whole-school diversity education programmes are another promising strategy for Tier 1 intervention since belonging at school is highly influenced by the attitudes and actions of others in the school environment. An example of this approach can be found in the LEANS (Learning about Neurodiversity at School) project [ 100, 101]. LEANS comprises a teaching programme, developed by a neurodiverse research team using participatory methods, which is aimed at primary-aged children. By equipping teachers with lesson plans and resources on the topic of neurodiversity, the programme aims to facilitate a more accepting social environment for neurodivergent pupils. Early results indicate that the programme is feasible and holds promise for promoting the understanding of, and positive attitudes towards, neurodiversity in young children [ 100].

Tier 2 intervention would involve the development of tailored support that acknowledges both the individual and contextual factors contributing to EBSA in a given case. Effective partnership working between schools and parents is crucial here since difficulties often become apparent earlier in the home environment while pupils engage in masking behaviour at school [ 47]. Unfortunately, research suggests that school staff tend to attribute extended absence from school to family-level factors, while conversely, parents and pupils identify school-level barriers to attendance [ 9, 102, 103]. Avoiding blame is conducive to establishing trusting home-school relationships, and if an action plan for return to school can be co-produced by pupils, parents and school staff, it is more likely to be adhered to (see McDonald et al. (2023) [ 104] for an example of an intervention for EBSA co-designed with parents). Action plans can draw on protective factors at school, for example, extracurricular clubs and activities that play to the pupil's strengths or a positive relationship with a peer or member of staff. Regular evaluation of progress and consultation with the pupil as to the usefulness of the strategies in play are also important [ 6]. For the most persistent cases of EBSA, where tailored, co-produced action plans are not effective in supporting a return to school, the involvement of outside agencies is likely to be necessary (Tier 3 intervention). In England, educational psychology services have developed intensive programmes to address EBSA in the post-pandemic context, prioritising feelings of psychological safety and nurturing relationships at school (e.g., [ 105, 106]). Additionally, alternative educational provision can ensure that learning continues when a pupil has been absent from mainstream school for lengthy periods. Providers that work in collaboration with the young person and their family, drawing on psychological insights to build confidence and work towards reintegration into the mainstream setting, can be particularly effective [ 107].

In summary, there is unlikely to be a single, one-size-fits-all approach to intervention for EBSA. Multi-tiered systems of support that seek to promote school belonging and agency in young people, holding compassionate regard for individual circumstances at their core, are recommended. Further research to systematically evaluate the effectiveness of different approaches to intervention for EBSA is needed.

6. Conclusions

The disruption to children and young people's education caused by containment measures in response to the COVID-19 pandemic is showing a long-lasting effect on some pupils' relationship with school. In the English context, this disruption came against a backdrop of rising mental health need in children and young people for the preceding decade. For a significant minority of pupils, many of whom are neurodivergent, school is experienced as a hostile environment, and absence from school is underpinned by chronic situational anxiety. The sharpened focus on improving school attendance at a policy level is welcome, given that existing educational inequalities are exacerbated by extended school absence in disadvantaged groups. However, any attempt to address this issue must acknowledge EBSA as a driver of school absence and adopt a psychologically informed approach to intervention.

In this article, school belonging and pupils' sense of (epistemic) agency have been identified as plausible mechanisms for change. Pupils exhibiting EBSA, including many autistic and neurodivergent pupils, often feel that they do not belong at school, following cumulative experiences of bullying, peer rejection, non-inclusive teaching practices, sensory stress and/or disciplinary policies that penalise neurodivergent ways of being in the world. They also often feel that they have little control over their school lives. Several sources of evidence now suggest that persistent absence from school grounded in EBSA is resistant to behaviourist reward-and-punishment approaches, which can further marginalise pupils with a range of disabilities. Instead, multiple systems of support approaches, which integrate pupil voice at all levels, are recommended. Universal, whole-school strategies for promoting positive mental health, acceptance of difference and tackling bullying can be combined with targeted processes for individual children at risk of chronic EBSA. All children have a right to education, and thus, an evidence-based strategy for supporting those experiencing EBSA at the local and national levels is essential.

AMA Style

Hamilton LG. Emotionally Based School Avoidance in the Aftermath of the COVID-19 Pandemic: Neurodiversity, Agency and Belonging in School. Education Sciences. 2024; 14(2):156. https://doi.org/10.3390/educsci14020156

Chicago/Turabian Style

Hamilton, Lorna G. 2024. "Emotionally Based School Avoidance in the Aftermath of the COVID-19 Pandemic: Neurodiversity, Agency and Belonging in School" Education Sciences 14, no. 2: 156. https://doi.org/10.3390/educsci14020156

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Emotionally Based School Avoidance in the Aftermath of the COVID-19 Pandemic: Neurodiversity, Agency and Belonging in School

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Lockdowns at the peak of the COVID-19 pandemic led to extended school closures globally, and in many countries school attendance has not recovered to pre-pandemic levels. In England, education leaders have expressed concern both about increased anxiety among pupils and chronic absenteeism post-pandemic, against a backdrop of over a decade of increasing mental health need among children and young people.

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Supported by Daniel Kebede, General Secretary, National Education Union

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Supported by Daniel Kebede, General Secretary, National Education Union