Background
School refusal is an increasingly serious issue among children. The term “school refusal” coalesces outdated terms such as truancy, school avoidance, school absenteeism, and school phobia. In 1941, the term “school phobia” first was introduced in clinical literature by Johnson [
1]. School refusal refers to a child’s refusal to attend school, as well as difficulties with remaining in school for an entire day, including missing entire or partial school days, skipping classes, or unjustifiably arriving late [
2]. Moreover, school refusal refers to a child’s inability to continue school for mental health reasons, such as anxiety and depression [
3]. According to the National Association of School Psychologists, individuals who avoid school are more likely to have long-term emotional issues, such as depression and anxiety, poor academic achievement, dropping out of school, and suicide [
3,
4]. School refusal is also a key risk factor for violence, injury, substance use, psychiatric disorders, and economic deprivation [
5]. The prevalence of school refusal has been reported to be approximately 1% in school-aged children, which is similar among both sexes [
6]. In Japan, the educational system is under the authority of the Ministry of Education, Culture, Sports, Science, and Technology (MEXT), which defines school refusal as the students’ lack of attendance for > 30 days per year for reasons other than sickness or economic causes, including psychological, emotional, physical, or social reasons [
7]. Currently, the number of students with school refusal is an increasingly serious issue in Japanese education. The total number of students in elementary and junior high schools has decreased from approximately 13 million in 1995 to 10 million in 2016 due to low birth rate. Conversely, the number of students with school refusal has increased from 81,591 in 1995 to 133,683 in 2016. Therefore, the rate of school refusal was > 1% in Japanese elementary and junior high school students in 2016 [
8]. Japanese children and adolescents aged 6–15 years are required to compulsorily attend school.
Reasons for school refusal are complicated and include biological, psychological, and social factors. Biological factors that impact school refusal include neurodevelopmental disorders, such as autism spectrum disorder (ASD) [
9]. ASD is a lifelong set of heterogeneous neurodevelopmental disorders characterized by developmental delays in social communication and repetitive behaviors [
10]. Some studies revealed that the rate of school refusal in children with ASD was significantly more than in children with typical development [
9,
11]. A markedly skewed sex distribution has been consistently reported in ASD, despite the recently improved recognition of autism in girls [
12]; the ratio is still estimated to be around 2–3 (boys):1 (girls) [
12,
13]. Wang et al. reported that girls with ASD show greater socio-emotional reciprocity, and nonverbal girls suffer increased communication impairment compared with boys [
14]. Differences might exist in the underlying etiology and symptom presentation of ASD among girls, which could be associated with both reduced risk of developing ASD, as well as failure of recognizing ASD in girls [
15]. School refusal associated with ASD might have different characteristics according to sex, although there are no reports of sex difference in this population.
One of the leading causes of school refusal is bullying [
16]. Olweus defined bullying as an aggressive behavior that is repetitive, intentional, and physically or emotionally hurtful [
17]. In Japan, MEXT uses two points to define bullying: (1) “We must judge not ceremonially but from the feelings of students who are bullied whether there is bullying or not” and (2) “Bullying is defined as those who are in relationships with someone and feel psychologically damaged because of a psychological or physical attack” [
18]. Research indicates that children with ASD are at a greater risk for being bullied victims and/or perpetrators [
19‐
21]. Previous studies in the USA, Canada, the UK, and the Netherlands reported bullying prevalence ranging from 7 to 75% for individuals with ASD as victims and from 19 to 46% as perpetrators [
19,
22‐
24]. Children with ASD are unable to develop the theory of mind (ToM), which is the ability to comprehend and describe mental states such as belief, intention, and emotion in themselves and others [
25], as they have difficulty understanding the concept of false belief.
Bullying might be one of the factors that lead to school refusal for students with ASD who have less developed ToM, which often leads to isolation and loneliness [
22], and adolescents with ASD are more likely socially withdrawn than TD individuals [
26], which might result in school refusal. In clinical settings, the school refusal rate was 12.2–28.6% in students attending Japanese schools [
27‐
29]. Although studies indicate that school refusal is a considerable problem in students with ASD, detailed studies observing an association between school refusal and ASD-related factors have not been performed. Moreover, the school education curriculum considerably varied between countries, and overseas data or papers were not as informative.
This study compared school refusal between children with and without ASD. Accordingly, we hypothesized that the characteristics of school refusal in children with ASD are different from those in children without ASD.
Discussion
This study showed that the age of onset of school refusal was 12.6 ± 2.2 years in children with ASD, which is earlier than 13.8 ± 2.1 years in children without ASD. Previous studies have indicated that the age at onset of school refusal for Japanese children with ASD was 10.6 ± 3.9 years; however, their results were not compared with those of children with typical development [
11]. School refusal is considered as a heterogeneous, complex condition caused and maintained by multiple interrelated factors. The cause of school refusal associated with ASD might be different. Two factors might affect school refusal among children with ASD. First, participants with ASD are directly influenced by school-related stress factors, such as bullying, poor academic performance, and changes in the class or teachers. Munkhaugen et al. speculated that students with ASD are especially vulnerable to stressful emotional events in coping with school situations [
32]. Second, participants may wish to avoid something unpleasant. Atypical responses or avoidance of eye contact in ASD can occur unconsciously, and these responses may be based on mechanisms of impaired social functioning [
33]. These facts suggest that school refusal in children with ASD may occur at a younger age than in those without ASD. Therefore, school refusal, particularly during elementary school, should be examined considering their neurodevelopmental characteristics. In summary, this study indicated that the onset of school refusal tended to be early among children with ASD.
A previous study has reported that bullying is one of primary factors for school refusal [
11]. Furthermore, participants with ASD experience bullying at school more often than those without [
20,
34‐
36]. Children with ASD display considerable difficulty in reciprocal social interactions with impaired social communication skills [
37]. There are interactive interpretations on bullying for children with ASD. Children with ASD may believe that peers are bullying them when this is not happening or children with ASD may interpret that peers are not bulling them when this is happening [
37,
38]. These difficulties can contribute to isolation from peers. Further, repetitive and ritualistic behaviors and restricted interests make children with ASD “stand-out” among their peers [
39]. These characteristics promote children with ASD to feel ridiculed [
19]. In this study, bullying was significantly associated with school refusal in both boys and girls with ASD. Van Roekel et al. have reported that the prevalence of bullying in children with ASD is higher in general classes than that in special education classes and that transferring to special education classes may reduce the prevalence of bullying [
37]. This study also focused on children with ASD studying in inclusive classes. A study indicated that bullying victimization can lead to increased anxiety in patients with ASD [
40]. Furthermore, children with ASD having symptoms of anxiety and depression showed increased risks of victimization [
41]. Bullying is related to the later development of psychopathology [
42]. Therefore, clinical psychiatrists should pay careful attention to children with ASD who refuse school because of bullying.
In terms of girls with ASD, maladjustment during school entry or promotions and physical symptoms were significantly associated with school refusal. The transition from primary to secondary school is considered challenging for students with ASD [
42]. The time of school entrance or promotions to children with ASD may be a major stress and may trigger the school refusal. Furthermore, students with ASD may experience difficulty in expressing their emotions regarding situations linked to the school setting [
43]. Children with ASD often cannot directly express their anxiety and emotional confusion. They might express their feelings as physical symptoms such as headaches and nausea. Girls with ASD are reported to be more likely to experience a lack of diagnosis, delay in diagnosis, or misdiagnosis than boys with ASD [
14]. In general, it is difficult for girls with ASD to grasp developmental characteristics and they may experience increased stress; therefore, it is vital to carefully diagnose ASD in girls than in boys.
Limitations
This study has several limitations. First, 71.3% of participants in the ASD group and 34.3% in the non-ASD group were boys, which might show differences between sexes rather than ASD/non-ASD. Our data could not completely compare characteristics of school refusal between the ASD and non-ASD group. Second, age was a relatively wide range. Therefore, characteristics of school refusal should be characterized according to the following age groups: 6–9, 9–12, 12–15 years, and 15–18 years, respectively. Third, participants did not undergo intelligence quotient (IQ) test. IQ differences might be related to some issues, such as difficulty in learning and poor communication due to delayed verbal development, which may allow the identification of different reasons for school refusal with or without intellectual issues. Fourth, confounding factors, such as domestic environment, including economic status, were not controlled. Therefore, future studies should investigate the effects of IQ, restricted age ranges, and domestic environment on school refusal.
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