The association between child and adolescent emotional disorder and poor attendance at school: a systematic review protocol

Emotional disorders are among the most common psychiatric disorders in children and adolescents, with worldwide prevalence estimates of 7 and 3% for anxiety and depressive disorders, respectively [1]. In addition, emotional disorders are identified as leading contributors to the burden of disease in young people [2]. In the short term, emotional disorders are associated with a range of adverse consequences including educational problems, difficulties at home and in social relationships, physical health problems, smoking and substance abuse [3, 4]. In the long term, they are associated with adult psychiatric disorder, substance abuse, increased risk of suicide, increased treatment utilisation and social impairments [5, 6]. Effective interventions for these disorders exist [7], yet rates of help-seeking remain low, with estimates suggesting that approximately 80% of children fail to access effective treatment [8, 9]. There is therefore a need to explore how emotional disorders in children and adolescents could be better detected, to allow for provision of appropriate support and intervention. Since the majority of children spend a large proportion of their time at school, teachers and other educational practitioners are well-placed to identify potential emotional disorders in young people. A recent report from the UK Department for Education (DfE) highlights the important role of schools in supporting children to be resilient and mentally healthy, and promotes the use of attendance data as one way of identifying children at risk of mental health problems [10]. In the UK, education is compulsory for all children from the school term immediately following their fifth birthday, and any child absent for 10% or more of school “sessions” (morning or afternoon) is considered “persistently absent” [11].

Traditionally, research has characterised persistent non-attendance at school in two broad categories: school refusal, reflecting non-attendance due to emotional distress and truancy, reflecting non-attendance due to a lack of interest in school or antisocial behaviour [12]. In practice, however, a broad range of labels are used, including school refusal, truancy, absenteeism, persistent non-attendance and school phobia. These terms are often used interchangeably, and there is little consensus about how best to define and assess the full spectrum of persistent non-attendance. In addition, there is evidence to suggest that school refusal and truancy are not mutually exclusive, leading some researchers to argue that a more inclusive approach is needed that makes no assumptions about the underlying aetiology [13]. Emotional disorder can be conceptualised in different ways but is generally considered to mean depression or anxiety [14]. Some studies examine diagnoses using standardised diagnostic measures, and others measure symptoms of depression or anxiety on a continuous scale. Studies may also refer to “internalising problems” or “internalising symptoms”, which are generally considered to mean a combination of depression and anxiety [15].

Studies have shown a relationship between emotional disorder and non-attendance at school. For example, McShane et al [16] found that 54 and 52% of children assessed or treated for school refusal in an Australian clinic had diagnoses of anxiety and mood disorders, respectively, and a large USA community sample found that 25% of anxious school refusers and 88% of mixed school refusers (i.e. those meeting criteria for both anxious school refusal and truancy) met criteria for a psychiatric disorder, compared to 7% of non-school refusers [17]. Somatic symptoms such as headaches, stomach aches and fatigue are commonly reported in children with emotional disorders, and there is some evidence that somatisation may be one of the pathways through which emotional disorders impact on school attendance [18]. Research investigating the relationship between emotional disorder and poor attendance at school has varied extensively in setting, sample sizes, use of comparators and definitions and methods of assessing both attendance and emotional disorder, making comparison between studies difficult, and we are aware of no systematic reviews that have addressed this relationship. Understanding the association between emotional disorder and poor attendance at school has the potential to assist in the development of strategies to improve the identification of and intervention for children with emotional disorder.

The objectives of this systematic review are to address the following research questions: