Recent studies suggest that young people with a record of a neurodevelopmental or mental disorder are more likely to have higher rates of absenteeism and are more likely to be excluded from school (Paget et al., 2018, Finning et al., 2019; Lawrence et al., 2019). These studies are typically small scale with diagnoses that are administered via questionnaire or interview.
The current study conceived by Professor Ann John from Swansea University Medical School (2022), however, aims to explore this association further at a population level (over 400,000 young people in Wales) using data sets which contain routinely collected information on primary and secondary healthcare, attendance and school exclusion.
This large, population scale study builds on recent research investigating an association between pupils with a reported neurodevelopmental or mental disorder and higher rates of school absenteeism and exclusion.
Methods
John and colleagues considered 414,637 pupils aged 7-16 years enrolled in mainstream Welsh schools in the academic years 2012/13 and 2015/16. These pupils all had primary and secondary care data available.
Pupils were identified who had a record of neurodevelopmental disorders (ADHD and ASD), learning difficulties, conduct disorders, depression, anxiety, eating disorders, alcohol or drugs misuse, bipolar disorder, schizophrenia, other psychotic disorders or recorded self-harm before the age of 24. Each pupil had a binary flag for each of the datapoints and the age at their first diagnosis was extracted. The number of flags for each pupil was also noted to assess the effect of comorbidities on absenteeism and exclusion. For the purpose of this study, absenteeism was set at 10% or above. Exclusion was simple binary marker, either excluded or not excluded.
The researchers used this data to conduct a retrospective electronic cohort study to explore the hypothesis that there is an association between school absenteeism, exclusion and neurodevelopmental and mental disorders and self-harm even after adjusting for age, gender and level of deprivation.
Results
Of the 414,637 pupils with primary and secondary care data available, 57,940 (14%) had a record of a disorder or self-harm. 42,734 (10.3%) had this recorded whilst still at school age.
Absenteeism
For those pupils with no record of a neurodevelopmental disorder, mental health disorder or self-harm, the proportion of pupil absentees remained constant at about 12.5% throughout primary school and began to rise in secondary school to 18% for 16-year-olds. There was a significantly higher proportion of absenteeism in those pupils with a neurodevelopmental or mental disorder or a record of self-harm. Those pupils who received a diagnosis of schizophrenia or drug misuse had the highest rate of absenteeism (around 30-33%). In secondary school, pupils with a record of bipolar disorder, schizophrenia, alcohol misuse, drug misuse or self-harm had the highest rates of absenteeism (40-55%). Comorbidity was a significant factor with absenteeism more likely in pupils with more than one disorder.
Exclusion
Of the children aged 7-11 in the study, those with a neurodevelopmental disorder, mental health disorder or self-harm were much more likely to be excluded than those without. The proportion of excluded pupils without a disorder was consistently low at 0.5%. However, of the children with an ASD record, 4.7% were excluded and of those with a conduct disorder record 8% were excluded.
This pattern was the same when considering the study as a whole. For those children with no listed disorder, exclusion became more common as they entered secondary education with rates rising to a high of 2.9% at aged 15 before falling to 2.2% in the final year of schooling. At age 14, pupils with a record of ADHD had an exclusion rate of 15.1%, conduct disorder 14.5%, drugs misuse 24.2%, alcohol misuse 14.6% and self-harm 10.7%. Exclusion rates were also high for those pupils with a record of severe mental illness such as bipolar disorder 18.4% and schizophrenia 18.4%.
Both absence and exclusion rates were significantly higher in those children with one of the neurodevelopmental or conduct disorders recorded.
Conclusions
The study concludes that young people with a record of a neurodevelopmental disorder, mental health disorder, conduct disorder or self-harm have an increased likelihood of absenteeism and exclusion and the long-term disadvantages (Aucejo and Romano, 2016; Hancock et al., 2017) that go with these. The researchers also conclude that exclusion and persistent absence may be an indicator of current or future mental health issues for children and that special educational needs status is a protective factor reducing the likelihood of being absent or excluded.
The researchers also concluded that exclusion and persistent absence may be an indicator of current or future mental health issues for children.
Strengths and limitations
This study links large data sets for education, health and deprivation across a country’s entire population. The size of the study allowed a breadth of disorders to be included which are not normally considered in small scale studies. It also avoids the selection bias and high attrition rate that can be associated with surveys, particularly in those studies which look at psychiatric disorders over time. The researchers are clear, however, that although the study finds an association between absence, exclusion and the markers listed, it is not able to discern the direction of the association. It may be that presenting with a disorder in school makes it more likely that a child is absent/ excluded or alternatively, it may be that absence and exclusion are risk factors in a child either developing a disorder or exacerbating an existing disorder. It is plausible that the association flows both ways and that each may feed the other in an ongoing cycle.
The binary nature of the exclusion data point is also a consideration when drawing conclusions. In this study, a child had either experienced an exclusion or had not. This means that a record of a single fixed-term exclusion is given the same weight as multiple permanent exclusions from different settings. As the association may be multi-directional, this lacks nuance when considering the possible impact of exclusion on a child. I would also have liked to see whether for those children with both an exclusion and a diagnosis at school age, the exclusion came before or after the diagnosis. This would allow consideration of whether a diagnosis may be a protective factor in a similar way to SEN status.
The retrospective nature of this cohort study avoids the attrition rate sometimes associated with cohort studies relating to mental health.
Implications for practice
I have been the headteacher of two mainstream primary schools and am now the head of an alternative provision for children excluded (or at serious risk of exclusion) from primary school. This study feels like an important, large-scale piece of work with clear implications for practice.
When primary aged children begin to present with absenteeism or their behaviour becomes such that exclusion is a risk, leaders should ensure that a child’s needs are assessed thoroughly and that adaptations are made to best meet those needs. Schools need access to good quality advice on appropriate adaptations. This should be well before a child is beginning to be excluded. Where external agencies are involved, however, this can be a lengthy, frustrating and time-consuming process. There are links here with Sarah Martin-Denham’s (2021) policy brief for the University of Sunderland which describes primary headteachers feeling the need to use exclusion as a way of accessing external assessment and support. Requiring schools to assess early is only a part of the picture. Assessing children thoroughly and making adaptations to meet their needs requires input from specialist, external agencies. Schools need timely access to these services without resorting to the use of exclusion as a trigger.
Once assessed, a child’s SEN status should then reflect the outcomes of those assessments. This study shows that appropriate SEN status is a protective factor against both absenteeism and exclusion and the long-term disadvantage that both these may bring.
Persistent absenteeism and risk of exclusion should be used as indicators for a child to have their needs fully assessed and their SEN status recorded appropriately.
Statement of interests
None
Links
Primary paper
John A, Friedmann Y, DelPozo-Banos M, Frizzati A, Ford T, Thapar A (2022) Association of school absence and exclusion with recorded neurodevelopmental disorders, mental disorders, of self-harm: a nationwide, retrospective, electronic cohort study of children and young people in Wales, UK. Lancet Psychiatry 9 23-34
Other references
Aucejo EM, Romano TF (2016) Assessing the effect of school days and absences on test score performance. Econ Educ Rev 55 70-87
Finning K, Ukoumunne OC, Ford T, et al (2019) The association between anxiety and poor attendance at school—a systematic review. Child Adolescent Mental Health 24 205–16.
Hancock KJ, Lawrence D, Shepherd CCJ, Mitrou F, Zubrick SRM (2017) Associations between school absence and academic achievement: do socioeconomics matter? Br Educ Res J 43: 415–40
https://bera-journals.onlinelibrary.wiley.com/doi/epdf/10.1002/berj.3267
Lawrence D, Dawson V, Houghton S, Goodsell B, Sawyer MG (2019) Impact of mental disorders on attendance at school. Aust J Educ 63: 5–21
Martin-Denham S. (2021) ‘The benefits of school exclusion: Research with headteachers in England’ University of Sunderland: Sunderland [
Paget, A, Parker, C,, Heron, J, Logan, S, Henley, W, Emon A, and Ford, T (2018) Which children and young people are excluded from school? Findings from a large British birth cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC). Child Care Health Developmentn44 (2) 285– 296
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