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 The term “school refusal” coalesces outdated terms such as truancy, school avoidance, school absenteeism, and school phobia.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 [19,20,21]. 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, 22,23,24]. 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 [27,28,29]. 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.