The association between home learning during COVID-19 lockdowns and subsequent school attendance among children with neurodevelopmental conditions.

BACKGROUND: Children with neurodevelopmental conditions have high levels of school absence. During the COVID-19 pandemic, schools closed for many students. The relationship between home learning during school closures and subsequent school attendance requires attention to better understand the impact of pandemic education policy decisions on this population. This study aims to investigate the association between home learning, hybrid learning and school learning during school closures (in January-March 2021) with subsequent school attendance (in May 2021) in children with neurodevelopmental conditions. METHODS: An online survey was completed by 809 parents/carers of 5- to 15-year-old autistic children and/or children with intellectual disability. Regression models examined the association of learning location during school closures with subsequent school absence (i.e., total days missed, persistent absence and school refusal). RESULTS: Children who were learning from home during school closures later missed 4.6 days of a possible 19. Children in hybrid and school learning missed 2.4 and 1.6 school days, respectively. The rates of school absence and persistent absence were significantly higher in the home learning group even after adjusting for confounders. Learning location was not associated with subsequent school refusal. CONCLUSIONS: Policies for school closures and learning from home during public health emergencies may exacerbate school attendance problems in this group of vulnerable children.

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

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

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

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

Truancy in the United States: Examining Temporal Trends and Correlates by Race, Age, and Gender.

BACKGROUND: Truancy has long been regarded a common problem in urgent need of effective intervention. Knowledge about factors associated with truancy can guide the development and implementation of interventions. METHOD: This paper examined trends in truancy rates between 2002-2014 and correlates of truancy across racial/ethnic groups. Variables of interest included sociodemographic factors (e.g., age, gender, socio-economic background), behavioral factors (e.g., substance use, violence), and psychosocial factors (e.g., academic engagement, grades, parental control). Using data from a large sample of adolescents (n=209,393; 12-17 years) we estimated truancy prevalence rates and examined trends and correlates via regression analyses. RESULTS: Truancy rates remained constant between 2002 (10.8%) and 2014 (11.1%). Rates were highest among older youth, females, and Hispanic youth. For all racial/ethnic groups, truancy was significantly correlated with alcohol and marijuana use, fighting, the propensity to take risks, and lower academic engagement and school grades. Other factors were differentially associated with racial/ethnic groups. This divergence in risk patterns for different racial/ethnic groups points to some heterogeneity amongst truant youth. DISCUSSION: Despite truancy reduction efforts, truancy rates have remained stable. Efforts to prevent truancy and to intervene with truant youth may need to target risk factors more prevalent in specific racial/ethnic groups.

The relation between social anxiety and audience perception: examining Clark and Wells' (1995) model among adolescents.

BACKGROUND: Clark and Wells' cognitive model of social anxiety proposes that socially anxious individuals have negative expectations of performance prior to a social event, focus their attention predominantly on themselves and on their negative self-evaluations during an event, and use this negative self-processing to infer that other people are judging them harshly. AIMS: The present study tested these propositions. METHOD: The study used a community sample of 161 adolescents aged 14-18 years. The participants gave a speech in front of a pre-recorded audience acting neutrally, and participants were aware that the projected audience was pre-recorded. RESULTS: As expected, participants with higher levels of social anxiety had more negative performance expectations, higher self-focused attention, and more negative perceptions of the audience. Negative performance expectations and self-focused attention were found to mediate the relationship between social anxiety and audience perception. CONCLUSIONS: The findings support Clark and Wells' cognitive model of social anxiety, which poses that socially anxious individuals have distorted perceptions of the responses of other people because their perceptions are coloured by their negative thoughts and feelings.

School participation of autistic youths: The influence of youth, family and school factors.

LAY ABSTRACT: School-aged youths have a basic human right to participate in educational and recreational activities at school. Yet, autistic youths are at high risk of being excluded from school and from school-based activities. It is important to understand how this occurs, to ensure that all autistic youths have opportunities to participate in school activities that are equal to the opportunities of their non-autistic peers. The present study investigated multiple influences on the school participation of autistic youths, including youth factors (age and autistic traits), family factors (parent education level and parental self-efficacy for supporting their child's schoolwork) and school factors (the impact of problems autistic youths experienced with the physical and social environments of school). Using an online survey, we gathered the views and experiences of the parents of 200 autistic youths aged between 4 and 16 years, in the Netherlands. We found that among the factors, only the impact of problems that autistic youths experienced with the physical environment of school was associated with their school participation. In particular, autistic youths who experienced greater difficulties with the physical environment of school had lower levels of school participation. Our findings highlight the pressing need to modify school environments to better accommodate the needs of autistic youths so that they can participate easily and comfortably.

The Effectiveness of Modular Transdiagnostic Cognitive Behavioral Therapy Versus Treatment as Usual for Youths Displaying School Attendance Problems: A Randomized Controlled Trial.

School attendance problems (SAPs) are associated with negative short- and long-term outcomes. Despite high prevalence of SAPs, there is a shortage of evidence-based interventions. Existing approaches often target either school refusal or truancy, leaving a gap in effective interventions addressing both types of SAPs. This randomized controlled trial (RCT) assessed the effectiveness of Back2School (B2S), a modular transdiagnostic cognitive behavioral therapy (CBT) for SAPs, compared to treatment as usual (TAU). Outcomes included youths' school attendance and mental health. A group (B2S, TAU) × time (Pre, Post, 3-Month Follow-Up) design involving 152 youths (B2S; n = 74, TAU; n = 78) with SAPs (i.e., ≥ 10% absence in the past three months), aged 6-16 years (M = 12.2, SD = 2.2, males = 60%) were used. B2S comprised three months of CBT with youths, parents, and school involvement, while TAU comprised public and/or private intervention services. On average, youths in B2S received 15.0, (SD = 3.9) hours of intervention, while those in TAU received 13.4, (SD = 21.6). Intervention effects were investigated using mixed linear models. Both B2S and TAU exhibited significant within-group improvements in school attendance, with no significant differences between them. However, the B2S group significantly outperformed TAU in reducing youths' emotional problems, conduct problems, problems with peers, the overall impact of problems, and increasing youths self-efficacy for attending school and parent self-efficacy for dealing with a SAP. This RCT represents the first evaluation of a modular transdiagnostic CBT for youths displaying SAPs, showing significant mental health and self-efficacy benefits.  (Clinical trial registration: ClinicalTrials.gov: NCT03459677).

Cognitive behavioral therapy age effects in child and adolescent anxiety: an individual patient data metaanalysis.

BACKGROUND: Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap. QUESTION: Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure? METHODS: All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects. RESULTS: Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust. CONCLUSIONS: Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.

Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal.

BACKGROUND: Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms. AIMS: Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal. METHOD: Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up. RESULTS: Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up. CONCLUSIONS: These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

School Attendance Problems Among Children with Neurodevelopmental Conditions One year Following the Start of the COVID-19 Pandemic.

PURPOSE: The present study investigated school absence among 1,076 5-15 year-old children with neurodevelopmental conditions (intellectual disability and/or autism) approximately one year following the start of COVID-19 in the UK. METHODS: Parents completed an online survey indicating whether their child was absent from school during May 2021 and the reason for each absence. Multi-variable regression models investigated child, family and school variables associated with absenteeism and types of absenteeism. Qualitative data were collected on barriers and facilitators of school attendance. RESULTS: During May 2021, 32% of children presented with persistent absence (missing ≥ 10% of school). School refusal and absence due to ill-health were the most frequent types of absence, accounting for 37% and 22% of days missed, respectively. COVID-19 related absence accounted for just 11% of days missed. Child anxiety was associated with overall absenteeism and with days missed because of school refusal. Parent pandemic anxiety and child conduct problems were not associated with school absenteeism. Hyperactivity was associated with lower levels of absenteeism and school refusal but higher levels of school exclusion. A positive parent-teacher relationship was associated with lower levels of absenteeism, school refusal and exclusion. Child unmet need in school was the most frequently reported barrier to attendance while COVID-19 was one of the least frequently reported barriers. CONCLUSION: COVID-19 had a limited impact on school attendance problems during this period. Findings highlighted the role of child mental health in different types of absence and the likely protective role of a positive parent-teacher relationship.

The role of cognition in school refusal: an investigation of automatic thoughts and cognitive errors.

AIMS: The purpose of this study was to investigate the cognitions of anxious school refusers. The cognitive constructs under investigation included negative cognition commonly linked to youth anxiety (i.e. negative automatic thoughts and cognitive errors) and positive automatic thoughts. METHOD: The cognition of school refusers (n = 50) and youth from a community sample (n = 181) was assessed with the Children's Automatic Thoughts Scale-Negative/Positive and the Children's Negative Cognitive Error Questionnaire-Revised. RESULTS: When controlling for anxiety, school refusers were found to report more negative automatic thoughts concerning personal failure, fewer negative automatic thoughts concerning hostility, and fewer positive automatic thoughts. Negative automatic thoughts concerning personal failure and hostility, and the negative cognitive error of overgeneralizing were found to independently predict school refusal. CONCLUSIONS: The findings underscore the importance of further researching the role of cognition in the development, maintenance, and treatment of anxiety-based school refusal.

Signposts for School Refusal Interventions, Based on the Views of Stakeholders.

School refusal (SR) signals a young person's difficulty attending school. It jeopardizes their development, often contributes to distress for parents, and places an extra burden on school personnel. Reviews of empirical studies indicate that intervention for SR helps to increase school attendance, but not for all youths. This practice-based manuscript aims to support practitioners and organisations addressing the needs of youths and families affected by SR. Specifically, we present 14 signposts for the development and delivery of intervention for SR. The signposts represent important conditions for effective intervention based on key findings from the Knowing What Works project in the Netherlands. During that project, 76 professionals shared their views about the important elements in SR interventions they delivered, and 39 youths and 86 parents shared their views about the helpful elements in SR interventions in which they participated. These 201 stakeholders were variously associated with 21 SR interventions across 9 of the 12 Dutch provinces, most situated in mainstream or special education settings. Their responses informed the development of the 14 signposts presented here, supported by the extant literature on SR intervention. We describe the essence of each signpost and conclude with suggestions for using the signposts and evaluating their utility.

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

BACKGROUND: Autistic youth are often bullied at school, which may lead to school refusal (SR). Currently, there is little research on factors that may help prevent SR among autistic youth. To advance theory-driven preventative interventions, this study examined associations between psychological resilience and emerging SR (ESR) among autistic youth bullied at school. METHODS: Fifty-eight autistic boys in elementary school (grades 1-6; n = 36) or secondary school (grades 8-11; n = 22) who were bullied at school responded to an online survey, as did their mothers. Boys reported on the experience of being bullied, psychological resilience (via the Social Emotional Assets and Resilience Scale), and ESR. Their mothers provided information regarding the boys' Autism Spectrum Disorder (ASD) diagnosis. RESULTS: Fifty-six percent of this sample of bullied autistic youth displayed ESR. For the secondary school boys there was a significant inverse relationship between psychological resilience and ESR, principally via two characteristics of psychological resilience: 'controlling negative thoughts' and 'remaining calm when angry'. No significant relationship was found between psychological resilience and ESR among elementary school boys. CONCLUSION: Longitudinal research is needed to determine whether psychological resilience serves as a factor protecting against the emergence of SR among autistic youth who have been bullied.

Sociodemographic and clinical characteristics of youths and parents seeking psychological treatment for school attendance problems.

BACKGROUND: Knowledge of school attendance problems (SAPs) is needed to inform treatments targeting SAPs and protecting youths from negative outcomes associated with SAPs. OBJECTIVES: This study examined the school absence, absence categories (i.e., absence due to illness, excused, non-excused), sociodemographic characteristics, and mental health problems among youths seeking psychological treatment for SAPs. METHODS: The study used a cross-sectional design. Sociodemographic and clinical characteristics of 152 help-seeking youths with SAPs (i.e., >10% absenteeism) and their parents were examined. The data were derived from the baseline assessment conducted before treatment start. RESULTS: Older youths, youths with mental health problems, and youths whose parents had mental health problems exhibited higher levels of absence. Lower levels of non-excused absence were found among youths with highly educated fathers, and youths living with both parents. Many youths had clinical levels of anxiety, depression, or 'emotional and behavioral difficulties'. CONCLUSION: The study highlights the need for early intervention, addressing a broad range of mental health problems. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT03459677.

Elective home education of children with neurodevelopmental conditions before and after the COVID-19 pandemic started.

COVID-19 brought disruptions to children's education and mental health, and accelerated school de-registration rates. We investigated Elective Home Education (EHE) in families of children with a neurodevelopmental condition. A total of 158 parents of 5-15 year-old children with neurodevelopmental conditions (80% autistic) provided information on reasons for de-registration, their experience of EHE, and children's mental health. Few differences were found between children participating in EHE before and after the pandemic started. Low satisfaction with school for not meeting children's additional needs was the main reason for de-registering in both groups. COVID-19 had a more limited role in parents' decision to de-register. The main advantage of EHE reported in both groups was the provision of personalised education and one-to-one support. Levels of anxiety, internalising and externalising problems were similar between children participating in EHE before and after the pandemic started, and also similar between all children in EHE and school-registered children (N = 1,079).

Is Bullying Associated with Emerging School Refusal in Autistic Boys?

The experience of being bullied is widespread among autistic youth. Relatively little empirical work has been done on the relationship between the bullying of these youth and school refusal (SR). This study of 67 school-age autistic boys (M = 11.7 years, SD = 2.3 years) examined several factors that may contribute to SR. Data regarding boys' age, generalised anxiety disorder (GAD), major depressive disorder (MDD), key ASD diagnostic criteria, and frequency of being bullied were collected. Results indicated that, while boys displaying emerging SR also had significantly higher GAD and MDD than boys without emerging SR, only the frequency of being bullied made a significant contribution to emerging SR. Implications for prevention and treatment of SR among autistic youth are discussed.

Assessing therapy-relevant cognitive capacities in young people: development and psychometric evaluation of the self-reflection and insight scale for youth.

BACKGROUND: The effectiveness of cognitive-behaviour therapy with young people may be influenced by a young person's capacity for self-reflection and insight. Clinicians who assess clients' proficiencies in these cognitive capacities can better tailor cognitive and behavioural techniques to the client, facilitating engagement and enhancing treatment outcome. It is therefore important that sound instruments for assessing self-reflection and insight in young people are available. AIMS: The aim of the current study was to translate and adapt the Self-Reflection and Insight Scale (SRIS) for use with a child and adolescent population (Study 1), and to evaluate the psychometric properties of the resulting measure, the Self-Reflection and Insight Scale for Youth (SRIS-Y; Study 2). METHOD: In Study 1 (n=145), the comprehensibility of the SRIS-Y was assessed in a community sample of children and adolescents. Study 2 (n=215) then explored the reliability and structural, convergent, and divergent validity of the SRIS-Y. RESULTS: The SRIS-Y was found to be comprehensible to young people, and had good reliability and structural validity. CONCLUSIONS: It appears that the SRIS-Y is a sound instrument for assessing therapy-relevant cognitive capacities in young people, of potential benefit in both research and clinical contexts. Future research foci include the predictive validity of the instrument.

A Scoping Review of Constructs Measured Following Intervention for School Refusal: Are We Measuring Up?

Reviews of the effectiveness of interventions for school refusal (SR) rely upon well-conducted primary studies. Currently there are no guidelines for those conducting primary studies about the measurement of outcome following intervention for SR. Most people would agree that it is important to measure school attendance as an outcome but there has been little discussion about other constructs that warrant measurement. To facilitate this discussion and support the development of guidelines, we conducted a scoping review of constructs measured in studies evaluating intervention for SR. We screened the title and abstract of 3,213 publications found in peer-reviewed journals between 1980 and 2019. After full text review of 271 publications, 50 publications describing 51 studies were included. Results address the frequency with which constructs were measured, along with instruments used, informants, and time-points for measurement. Based on the results, we offer guidelines for choosing constructs to measure following intervention for SR and considerations for how to measure the constructs. Guidelines can increase consistency across primary studies, with benefits for future meta-analyses and international comparisons. They also provide support for practitioners contemplating routine evaluation of their interventions for SR. Ultimately, a core outcome set for SR can be developed.

Feasibility Study of Back2School, a Modular Cognitive Behavioral Intervention for Youth With School Attendance Problems.

There is large heterogeneity among youth with school attendance problems (SAPs). For this reason, protocols for the treatment of SAPs need to be flexible. Back2School (B2S) is a new manual-based, modular transdiagnostic cognitive behavioral intervention to increase school attendance among youth with SAPs. It also aims to increase the self-efficacy of these youth and their parents. B2S includes evidence-based modules addressing youth anxiety, depression, and behavior problems, together with modules focused on parent guidance and school consultation. The current study examined the feasibility of evaluating B2S in an randomized controlled trial and acceptability of the B2S program in a non-randomized trial, including both qualitative and quantitative data, in preparation for a randomized controlled trial of its effectiveness. Youth, parents, and teachers completed questionnaires at baseline, post-intervention, and follow-up. School attendance data were collected from school registers. Twenty-four youth with a SAP (defined as more than 10% absenteeism during the last 3 months) were recruited from primary and lower secondary schools in Aarhus Municipality, Denmark. Their parents also participated in B2S. Two of the 24 families withdrew during the intervention, after sessions two and six respectively. Of the remaining 22 families, 19 (86%) completed all 10 sessions. Parents and youth rated their satisfaction with B2S as high, and high levels of satisfaction were maintained 1 year after the intervention. Teacher satisfaction was lower than that of youth and parents, but the majority found the school's participation in the intervention helpful. Preliminary evaluation of intervention outcomes showed significant increase in school attendance and decrease in psychological symptoms, as well as a significant increase in self-efficacy for both youth and parents. Based on this feasibility data, adaptations were made to the B2S manual and study procedures prior to commencement of a randomized controlled effectiveness trial. The main adaptation to the manual was to increase school consultation. The main procedural adaptation was to broaden recruitment. Furthermore, it was necessary to increase level of staffing by psychologists because treatment delivery was more time consuming than expected.