Form, Function and Feedback on the School Refusal Assessment Scale--Revised in Children on the Autism Spectrum
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| Title: | Form, Function and Feedback on the School Refusal Assessment Scale--Revised in Children on the Autism Spectrum |
|---|---|
| Language: | English |
| Authors: | Adams, Dawn (ORCID |
| Source: | Journal of Autism and Developmental Disorders. May 2022 52(5):2156-2167. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 12 |
| Publication Date: | 2022 |
| Document Type: | Journal Articles Reports - Research |
| Education Level: | Elementary Education |
| Descriptors: | Measures (Individuals), Autism, Pervasive Developmental Disorders, Children, Attendance, Elementary School Students, Factor Analysis, Usability |
| DOI: | 10.1007/s10803-021-05107-4 |
| ISSN: | 0162-3257 |
| Abstract: | School refusal is more prevalent in children on the autism spectrum than among their peers. The function of school refusal can be explored using the school refusal assessment scale--revised (SRAS-R) but its relevance to children on the spectrum has not been investigated. Parents of 121 children ("M" age 11.9 years) on the autism spectrum completed the SRAS-R and provided feedback on it applicability. Confirmatory factor analysis suggests unsuitability of the original four-factor structure proposed for neurotypical students. Only 41.7% of parents considered the questionnaire an adequate method for reporting on school refusal in children on the autism spectrum with the majority (90%) identifying additional questions to evaluate factors associated with school refusal in autism. |
| Abstractor: | As Provided |
| Entry Date: | 2022 |
| Accession Number: | EJ1333222 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwF0g9CIZ2LnVKm-wgep7aE5AAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDAuAAZtR_Q2DEgzMlgIBEICBm1R8vozrIPFhGQkXSpP4_sIi_Y5s_tLveXS5IGUSJdHlW-ZPFzHYcqxxMK4xqK_NOZVSzNT947rCxzgPTm13bIAm3XR27WSbTo4JG_WOGu9FPt0m0PfVNakaz8bAuV1mG79HnM7xX13jE5LiHBwaon3iwQOcQQEVuqfRV3rWT-RROkIgo9BQK-zFD2t4DXzS9cpj6FmJvtKdI-u0 Text: Availability: 1 Value: <anid>AN0156413873;aut01may.22;2022Apr22.02:35;v2.2.500</anid> <title id="AN0156413873-1">Form, Function and Feedback on the School Refusal Assessment Scale-Revised in Children on the Autism Spectrum </title> <p>School refusal is more prevalent in children on the autism spectrum than among their peers. The function of school refusal can be explored using the school refusal assessment scale-revised (SRAS-R) but its relevance to children on the spectrum has not been investigated. Parents of 121 children (M age 11.9 years) on the autism spectrum completed the SRAS-R and provided feedback on it applicability. Confirmatory factor analysis suggests unsuitability of the original four-factor structure proposed for neurotypical students. Only 41.7% of parents considered the questionnaire an adequate method for reporting on school refusal in children on the autism spectrum with the majority (90%) identifying additional questions to evaluate factors associated with school refusal in autism.</p> <p>Keywords: ASD; Anxiety; School attendance; School anxiety; Psychometrics</p> <hd id="AN0156413873-2">Introduction</hd> <p>Children on the autism spectrum experience a range of challenges with school, including decreased participation (Simpson et al., [<reflink idref="bib43" id="ref1">43</reflink>], [<reflink idref="bib42" id="ref2">42</reflink>]) and poorer academic outcomes (Keen et al., [<reflink idref="bib26" id="ref3">26</reflink>]; Mayes et al., [<reflink idref="bib29" id="ref4">29</reflink>]) than their neurotypical peers. A recent review concluded that the research to date has not identified any consistent predictors of academic achievement in children on the spectrum (Keen et al., [<reflink idref="bib26" id="ref5">26</reflink>]), highlighting the need for more work in the area. Whilst some factors, such as the impact of sensory sensitivities on learning (Howe &amp; Stagg, [<reflink idref="bib21" id="ref6">21</reflink>]), may be autism specific, other factors that impact academic outcomes may not be autism specific, but may occur more frequently and/or have a greater impact on learning in those on the autism spectrum. One example of this might be school non-attendance; school non-attendance and school absenteeism have been shown to impact academic skills and outcomes in neurotypical children (Crede et al., [<reflink idref="bib10" id="ref7">10</reflink>]). Chronic school non-attendance and absenteeism (missing 10% or more of the school year) reduces math and reading achievement outcomes, reduces educational engagement, and decreases social engagement (Gottfried, [<reflink idref="bib14" id="ref8">14</reflink>]). Students on the autism spectrum experience chronic absenteeism at almost four times the rate of neurotypical children (Black &amp; Zablotsky, [<reflink idref="bib5" id="ref9">5</reflink>]), highlighting this as a potential factor leading to academic underachievement. While this rate is concerning, it may actually represent an underestimate of the broader school attendance problems as it only reports on attendance data and thus does not include those who attend but have significant difficulties getting to school each day [see Kearney ([<reflink idref="bib24" id="ref10">24</reflink>]) for a discussion of the types of problematic school attendance].</p> <p>"School attendance problems" is the umbrella term used to encompass a range of problematic absences from school, including truancy (missing part or all of a school day without permission from school or parents), school exclusion (absenteeism due to school-based decisions like inability to accommodate for special needs), school withdrawal (when parents withdraw children from the school day), and school refusal (Heyne et al., [<reflink idref="bib18" id="ref11">18</reflink>]). School refusal is characterised as a school absence which parents have knowledge of and one where parents have made reasonable attempts to get their child to school. Heyne et al. ([<reflink idref="bib18" id="ref12">18</reflink>]) stipulate that school refusal has an emotional component, which may include an internalising disorder like anxiety or emotional distress around attending school, but does not include conduct disorders. Using the School Non-Attendance ChecKlist (Heyne et al., [<reflink idref="bib18" id="ref13">18</reflink>]) which assesses for all these types of school attendance problems, Totsika et al. ([<reflink idref="bib44" id="ref14">44</reflink>]) reported that, on average, students on the autism spectrum miss five school days each school month. They also note that 64% of students on the autism spectrum missed at least one day each month and 43% missed more than 10% of school days. The most common reason for school non-attendance was school refusal, which accounted for 43% of the days missed across the sample of 486 participants. Similarly, Munkhaugen et al. ([<reflink idref="bib32" id="ref15">32</reflink>]) reported that 43% of the children on the autism spectrum in their sample experienced school refusal ranging from 1 to 20 days out of a possible 20 school days per month.</p> <p>Despite school refusal being the most frequent cause of school non-attendance in students on the autism spectrum, only four studies (all published in the last two years) have looked at factors which impact or predict higher school refusal in students with a diagnosis on the autism spectrum. Two (Bitsika et al., [<reflink idref="bib4" id="ref16">4</reflink>]; McClemont et al., [<reflink idref="bib30" id="ref17">30</reflink>]) focussed solely on the association between school refusal due to bullying, noting an association between the two. Using a sample of children on the autism spectrum as well as a neurotypical sample, Ochi et al. ([<reflink idref="bib35" id="ref18">35</reflink>]) found that school refusal onset is earlier in children on the autism spectrum than in neurotypical children, highlighting the importance of identifying and intervening for school refusal even in the early school years. The impact of a student's cognitive profile and academic skills was highlighted in Munkhaugen et al. ([<reflink idref="bib33" id="ref19">33</reflink>]) who reported lower social motivation, challenges with executive functioning and more withdrawn/depressive symptoms as risk factors for school refusal. The limited research in this area highlights that school refusal is a substantial problem for children on the spectrum but, at present, studies to date only document prevalence and statistical correlates. In order to better support children on the autism spectrum experiencing school refusal, it is necessary to understand the reasons for its onset and maintenance. The school refusal assessment scale-revised (SRAS-R; Kearney &amp; Albano, [<reflink idref="bib25" id="ref20">25</reflink>]) aims to identify the reasons for school refusal, categorising it into four functions: avoidance of negative affect, escape from aversive social or evaluative situations, pursuit of attention from significant others, and pursuit of tangible reinforcement. The scale has been translated into multiple languages (Secer, [<reflink idref="bib40" id="ref21">40</reflink>]; Walter et al., [<reflink idref="bib45" id="ref22">45</reflink>]) and used both to determine functions of school refusal (Dube &amp; Orpinas, [<reflink idref="bib12" id="ref23">12</reflink>]; Gonzalvez et al., [<reflink idref="bib13" id="ref24">13</reflink>]) and to explore associations between functions of school refusal and anxiety (Gonzalvez et al., [<reflink idref="bib13" id="ref25">13</reflink>]) in a variety of populations.</p> <p>To date, the SRAS-R has not been investigated with children on the autism spectrum. While it has been widely used in neurotypical populations, its immediate applicability to children on the autism spectrum cannot be assumed. Given the differing psychometric properties of the SRAS-R parent version (SRAS-R-P) in different populations, it is important for the psychometrics to be explored prior to its use in children on the spectrum as it may be that differing factors are interacting to cause school refusal in individuals on the spectrum. In addition, just as there has been a recognition that measures of anxiety and quality of life designed for neurotypical children may not capture the entire experience of anxiety or quality of life for those on the autism spectrum (see McConachie et al., [<reflink idref="bib31" id="ref26">31</reflink>]; Rodgers et al., [<reflink idref="bib37" id="ref27">37</reflink>]), it may be that the SRAS-R is not assessing for autism-specific aspects of school refusal (e.g., avoiding adverse sensory stimulation at school). The aims of this study are therefore (a) to explore the statistical reliability of the established scales of the SRAS-R-P in a community sample of individuals on the autism spectrum and conduct a confirmatory factor analysis to identify whether the four-factor structure widely used in the neurotypical student population is suitable for this sample of children on the autism spectrum, and (b) to gain feedback from parents of children on the spectrum as to the appropriateness and comprehensiveness of the SRAS-R-P for identifying factors which contribute to or cause school refusal in individuals with school refusal.</p> <hd id="AN0156413873-3">Method</hd> <p>Ethical clearance for this study was granted through the Griffith University Human Research Ethics Committee, approval number 2019/462.</p> <hd id="AN0156413873-4">Recruitment Procedures</hd> <p>Parents of children on the autism spectrum were recruited through research centre social media posts which were shared by individuals and organisations. Parents completed the questionnaire online and could save and return to their answers over multiple sittings if needed. In total, 155 parents began the questionnaire. Seven were excluded as they did not go past the demographics page and 27 were excluded as their score on the Social Communication Questionnaire (SCQ; Rutter et al., [<reflink idref="bib38" id="ref28">38</reflink>]) was below the cut-off of 15 or their SCQ questionnaire administered as part of the questionnaire pack was incomplete.</p> <hd id="AN0156413873-5">Participants</hd> <p>After exclusions, the sample consisted of data from parents of 121 children on the autism spectrum. The sample were predominantly parents of boys (<emph>n</emph> = 81; 66.9%) with a mean age of 11.9 years (<emph>SD</emph> = 6.0 years). All but six children lived full-time with the parent completing the questionnaire. The six children who did not live with that parent full-time had shared parental custody arrangements but lived with the parent completing the questionnaire for at least half of the week. Demographic information for the children and caregivers is presented in Table 1. Parent informants were predominantly mothers (<emph>n</emph> = 112, 92.6%), with those remaining stating they were the child's father (<emph>n</emph> = 4), carer (<emph>n</emph> = 1), parent (<emph>n</emph> = 3), or grandparent (<emph>n</emph> = 1).</p> <p>Table 1 Child and Caregiver Demographics Based Upon Parent Report (N = 121)</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" colspan="2" /&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;N&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;%&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" colspan="4"&gt;&lt;p&gt;Child demographics&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Gender of child&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;81&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;66.9&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="6"&gt;&lt;p&gt; Formally diagnosed co-occurring diagnoses&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Anxiety&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;80&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;66.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Depression&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;ADHD/ADD&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;50&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;41.3&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Motor difficulties/Dyspraxia&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Speech and language disorder&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Intellectual disability&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="4"&gt;&lt;p&gt; Taking medications or supplements&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Any&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;83&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;68.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Melatonin&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;32&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26.4&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Anxiety medication&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;25&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.7&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;ADHD medication&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17.4&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="4"&gt;&lt;p&gt;Caregiver demographics&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Relationship to child&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mother&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;112&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;92.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt; Parent self-reported diagnoses (lifetime)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mental health disorder&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;40&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;33.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Autism&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Education level&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Tertiary level&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;92&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;76&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="5"&gt;&lt;p&gt; Family income (AUD$)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Below $37,000&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;24&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;$37,001-$80,000&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;$80,001-$180,000&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;45&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;37.2&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;$180,001 or above&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Did not wish to disclose&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <hd id="AN0156413873-6">Measures</hd> <p></p> <hd id="AN0156413873-7">Demographic Characteristics</hd> <p>Demographic characteristics were collected using a parent questionnaire focusing upon child (age, gender, age at diagnosis), parent (education, employment), and household (income) variables.</p> <hd id="AN0156413873-8">School Refusal</hd> <p>The 24-item school refusal assessment scale revised—parent version (SRAS-R-P; Kearney, [<reflink idref="bib22" id="ref29">22</reflink>]) assessed school refusal across four functions: avoidance of negative affect, escape from aversive social or evaluative situations, pursuit of attention from significant others, and pursuit of tangible reinforcement. Parents are asked to rate the frequency in which each event or situation may occur on a 7-point response scale (0 = <emph>never</emph>, 6 = <emph>always</emph>), although the timeframe across which they are meant to make their rating is not specified. The total score is not used as the scale is not designed to measure a single trait or type of school refusal. Heyne et al. ([<reflink idref="bib19" id="ref30">19</reflink>]) summarised the five factor analytic studies reporting on confirmatory factor analysis (CFA) of the SRAS-R-P in neurotypical children. They noted that two studies yielded a three-factor solution (combining the avoidance of negative affect and escape from aversive social or evaluative situations) and three yielded a four-factor solution. Following the CFA, some studies have suggested exclusion of specific items, although the specific items to be removed are inconsistent across studies. As this is the first study to explore the SRAS-R-P in a sample of children on the autism spectrum, the full questionnaire was administered to explore the utility and validity of all the items originally proposed and the most commonly reported (i.e. the four-factor) structure evaluated in terms of model-fit. Each subscale contains six items.</p> <p>After completing the SRAS-R-P, parents were asked to provide feedback on its relevance to their child on the autism spectrum through the following questions: "Did you feel this questionnaire is appropriate for exploring school refusal in children with a diagnosis on the autism spectrum?" and "Did you feel that it was missing any questions to find out about a child's school refusal or difficulties getting to school? If so, what else should be covered?".</p> <hd id="AN0156413873-9">Data Analysis</hd> <p>All quantitative analyses were conducted using the statistical package for the social sciences version 26. The profile of school refusal within this sample was examined by item-level analysis of the school refusal scales (SRAS-R-P) and included frequency endorsement, means, and standard deviations. Missing data were left as missing (rather than replaced) to allow for an examination of items that parents may not feel able to, or may not want to, answer.</p> <p>Scale reliability analyses were conducted to examine whether patterns of school refusal observed with neurotypical children held in children on the autism spectrum. As is commonplace when there is an established structure for a measure, the accepted four-factor structure model was examined under a Confirmatory Factor Analysis (CFA) using StataIC Version 16. As per previous CFAs of the SRAS-P in neurotypical samples (Kearney, [<reflink idref="bib23" id="ref31">23</reflink>]), three goodness-of-fit indices which are relatively resistant to sample size will be used to test the four-factor model: comparative fit index (CFI), standardized root mean-square residual (SRMR), and root mean square error of approximation (RMSEA). In addition, Chi-square will be used, although this is acknowledged as potentially being over-inclusive (i.e., it may fail to reject an unfitting model with small sample sizes). Acceptable goodness-of-fit in this study was defined as CFI values of 0.90 + and SRMR and RMSEA values of &lt; 0.10. In addition, the upper end of the 90% confidence interval for the RMSEA should be &lt; 0.10 and the significance level of χ2 should &gt; 0.05 (see review on goodness of fit statistics for CFA: Schreiber et al., [<reflink idref="bib39" id="ref32">39</reflink>]).The sample size (n = 121), whilst modest for a CFA, is not dissimilar from the sample sizes used for previous CFAs on the SRAS-P (e.g., <emph>N</emph> = 115, Kearney, [<reflink idref="bib23" id="ref33">23</reflink>], <emph>N</emph> = 131 Heyne et al., [<reflink idref="bib19" id="ref34">19</reflink>]).</p> <p>Finally, a summary of the frequently mentioned topics in the parent feedback on the SRAS-R-P was collated. The responses to the open-ended questions resulting in open-ended question data were coded using content analysis, a method often used for summarising open-ended answers in online questionnaires (e.g., Adams et al., [<reflink idref="bib2" id="ref35">2</reflink>]). The steps of Dey ([<reflink idref="bib11" id="ref36">11</reflink>]) were followed, which were (<reflink idref="bib1" id="ref37">1</reflink>) divide the data into manageable parts, (<reflink idref="bib2" id="ref38">2</reflink>) collect responses together that relate to the areas or questions of interest, (<reflink idref="bib3" id="ref39">3</reflink>) create categories that describe similar responses within these general groupings, and (<reflink idref="bib4" id="ref40">4</reflink>) combine or split categories where data can best be described in a rearranged structure. Parents could write as much as they liked in the box, so their response could be coded under more than one code for each question. As per previous research using this approach with parent data (e.g., Clark &amp; Adams, [<reflink idref="bib8" id="ref41">8</reflink>]), categories which had less than 5% responses within them were subsumed into a new combined category, where possible and logical (e.g., if anxiety had 10% and depression had 4%, a new category of "mental health" could be made from the combined responses). Half of the parent responses were double coded to ensure inter-rater reliability with 100% agreement between both raters.</p> <hd id="AN0156413873-10">Results</hd> <p></p> <hd id="AN0156413873-11">Profile of Responses on the SRAS-P</hd> <p>On average, parents reported that in the four weeks prior to completing the questionnaire, children had missed 10.8 of the possible 20 school days due to school refusal. Given the limited research on school refusal in children on the autism spectrum and that the SRAS-R-P has not been reported upon within this population, it was deemed appropriate to explore the data at item level in order to understand the profile of school refusal behaviours reported by parents of children on the spectrum. Table 2 presents the frequency of endorsement for each item on the SRAS-R-P questionnaire.</p> <p>Table 2 Means, Standard Deviations, and Proportion of Responses at each Frequency for each SRAS-R-P Item (see Kearney [2002] for exact wording of questions) (sorted from highest to lowest mean score)</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2" /&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Mean (SD)&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="8"&gt;&lt;p&gt;% endorsing&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Never&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Seldom&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Sometimes&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Half the time&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Usually&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Almost always&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Always&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Not answered&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;21. The frequency the child has more bad feelings about going to school compared to other children their age&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4.7 (1.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;38.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;23. Child likes to be at home with a parent more than other children their age would&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4.4 (1.9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;38.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;11. Child would rather be with their family than go to school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4.4 (1.7)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;38.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;17. It would be easier for the child to get to school if they had had less bad feelings about school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4.2 (1.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;25.6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;3. Child feels they would rather be with parent than go to school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;4.2 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;13.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;34.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;9. Child feels worse at school (e.g., scared, nervous, or sad) than they do when at home with friends&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.9 (1.9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;18.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;13.2&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;13. Child has bad feelings about school (e.g., scared, nervous or sad) when they think about school at the weekend&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.7 (1.9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;10.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;1. Child has bad feelings about going to school because he/she is afraid of something related to school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.6 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;22.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;18. It would be easier for the child to get to school if it were easier for the child to make new friends&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.5 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;15. Child would prefer to be taught by a parent at home rather than by his/her teacher at school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.4 (2.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;18.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;10.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;33.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;7. Child thinks about parents when in school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.21 (1.7)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;24.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;22. The frequency the child stays away from people at school compared to other children their age&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;3.2 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;22.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;19. It would be easier for the child to get to school if a parent went with them&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.8 (2.1)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.9&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;25.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;14. Child stays away from specific areas in school (e.g., hallways, places where certain groups of people are) where he/she would have to talk to someone&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.5 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;10.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;12. Child gets to enjoy doing different things (e.g., being with friends, going places) when not in school during a term time school day&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.3 (1.7)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;13.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;24.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;22.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;24. Child would rather be doing fun things outside of school more than most kids their age&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.2 (1.9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;30.6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9.9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;2. Child stays away from school as they find it hard to speak to peers at school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.1 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;10.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;5. Child stays away from school because they feel sad or depressed if they go to school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;2.0&lt;/p&gt;&lt;p&gt;(1.9)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;26.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;6. Child stays away from school because he/she feels embarrassed when in front of the other people there&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.8 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;29.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;15.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;10. Child stays away from school because of not having any friends there&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.8 (1.8)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;28.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.3&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;8. Child talks to or sees other people (other than family) when not in school during a term time school day&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.8 (1.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;33.1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;28.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;4. Child gets to do fun things outside the house when they miss school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.6 (1.3)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;34.7&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;20. It would be easier for the child to get to school if they could do more things they like to do after school hours (e.g., play with friends)&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.5 (1.6)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;24.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;27.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.4&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;16. Child refuses to go to school because they want to have fun outside of school&lt;/p&gt;&lt;/td&gt;&lt;td char="(" align="char"&gt;&lt;p&gt;1.2 (1.4)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;34.7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;28.9&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;18.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.8&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.8&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>The three items with the highest mean score (i.e., those which are rated as occurring most frequently across the sample) were items 21 (frequency of bad feelings about school compared to peers, originally from the <emph>Avoidance of stimuli provoking negative affect</emph> subscale), 23 (child would prefer at home with parent/caregiver than go to school, originally from the <emph>Pursuit of attention from others</emph> subscale), and 11 (child would prefer to be with family rather than go to school, originally from the <emph>Pursuit of attention from others</emph> subscale). All three of these items were rated as <emph>almost always</emph> or <emph>always</emph> by more than half of the sample and two of the three items (21 and 11) were rated as <emph>never</emph> or <emph>seldom</emph> by less than 10% of the sample.</p> <p>The three items with the lowest mean score (i.e., those which are rated as occurring the least frequently across the sample) were items 16 (the frequency with which the child refuses to go to school as they want to have fun), 20 (whether it would be easier for the child to go to school if they could do fun things after school), and 4 (the frequency with which the child gets to do fun things when they miss school). All three of these items were originally from the <emph>Pursuit of tangible reinforcement outside of school</emph> subscale, they were all rated as <emph>never</emph> or <emph>seldom</emph> by more than half of the sample, and all of the three items were rated as <emph>almost always</emph> or <emph>always</emph> by less than 7.5% of the sample.</p> <p>Four items were missing responses from more than 10% of participants and two (Items 14, child stays away from specific areas at school where they would have to speak to people; and Item 7, child thinks about parents when at school) had missing responses from more than 15% of respondents. As both of these items require children to be able to verbalise their internal thoughts to parents when they return home, the overlap between missing data on these two items and parents reporting that their child had an intellectual disability or speech and language disorder (both of which may impact the ability for children to verbalise these experiences to their parents) were explored. Seven (27%) out of the 26 who did not respond to Item 7 and four (20%) out of the 20 who did not respond to Item 14 reported their child had a formal or informal diagnosis of intellectual disability and/or speech or language disorder. Therefore, it cannot be assumed that it was only parents of children with an intellectual disability or speech and language disorder that felt unable to rate these items for their child.</p> <hd id="AN0156413873-12">Scale Reliability and Confirmatory Factor Analysis of the four-factor model of the SRAS-P</hd> <p>The SRAS-R-P items were summed into the four original subscales suggested by Kearney ([<reflink idref="bib22" id="ref42">22</reflink>]). Initial Cronbach's alphas indicated variability in the reliability of the subscales. Alpha was 0.80 for <emph>Avoidance of stimuli provoking negative affect</emph> subscale, 0.79 for <emph>Escape from aversive social and/or evaluative situation,</emph> 0.83 on <emph>Pursuit of attention from others,</emph> and 0.71 for <emph>Pursuit of tangible reinforcement outside of school</emph>. These are almost all below the minimum level recommended for basic research (0.80) (Carmines &amp; Zeller, [<reflink idref="bib7" id="ref43">7</reflink>]; Nunnally, [<reflink idref="bib34" id="ref44">34</reflink>]).</p> <p>A CFA was undertaken to test the original four-factor, 24-item model for the SRAS-R-P proposed by Kearney ([<reflink idref="bib22" id="ref45">22</reflink>]). The four-factor model was not supported by all four indices of fit (<emph>χ</emph>2 p &lt; 0.001, CFI = 0.73, SRMR = 0.12, and RMSEA = 0.12, 90% confidence interval: 0.12–0.13). As seen in Fig. 1, equation-level goodness of fit data highlights that the items with the weakest path coefficients to the four-factor subscales were question 17 (path coefficient 0.06, R<sups>2</sups> 0.003, <emph>Avoidance of negative affect</emph> subscale), question 18 (path coefficient 0.21, R<sups>2</sups> 0.04, <emph>Escape from aversive social or evaluative situations</emph> subscale), item 19 (path coefficient 0.40, R<sups>2</sups> 0.16, <emph>Pursuit of attention from significant others</emph> subscale) and item 16 (path coefficient 0.42, R<sups>2</sups> 0.17, <emph>Pursuit of tangible reinforcement outside of school</emph> subscale). The CFA was repeated with items with a path coefficient removed (i.e. items 17 and 18) to see if this improved fit. The four-factor model with the 22 items was still not supported by all four indices of fit (<emph>χ</emph>2 p &lt; 0.001, CFI = 0.76, SRMR = 0.12, and RMSEA = 0.12, 90% confidence interval: 0.10–0.13).</p> <p>Graph: Fig. 1 Outcomes of CFA analysis on all 24 items of the SRAS-R-P</p> <hd id="AN0156413873-13">Parent Feedback on the SRAS-R</hd> <p>Of the 96 parents who responded to the first feedback question ("Did you feel this questionnaire is appropriate for exploring school refusal in children with a diagnosis on the autism spectrum?"), 56 (58.3%) said "yes". Of those who answered "no", 21 (21.9%) parents noted general issues with the questionnaire (e.g., it didn't allow parent to provide the answer they wanted, the questions were not detailed enough, the answer options were unclear e.g., scale/examples required more or different options, they found it hard to answer the questions as all children or situations different/change over time/child doesn't share information). Eleven (11.5%) stated that the questions were not applicable to their child's level or did not ask about their child's needs or challenges (e.g., social skills, emotional needs, anxiety or fatigue, school level). Eleven (11.5%) also noted that the questions did not consider different schooling options and/or supports, for example, part-time schooling or home schooling, and five (5.2%) felt that the questionnaire did not ask about any issues or factors triggering school refusal.</p> <p>Of the 81 parents who responded to the second feedback question ("Do you feel that it was missing any questions to find out about a child's school refusal or difficulties getting to school? If so, what else should be covered?"), only 10 (12.3%) parents selected "no". The remaining 71 parents described areas which they felt the questionnaire needed to ask about in order to understand school refusal in children on the autism spectrum. These were coded into the following categories: sensory/school environment (noted by 21.1% of parents), school knowledge of autism and child-teacher relationship (16.9%), academic demands (too high or low; 12.7%), available supports and how safe the child feels at school (11.3%), anxiety (9.9%), bullying and social issues (9.9%), and the child being overwhelmed or exhausted (7.0%). Parents also stated that it would be helpful if they had a space to describe the presentation, duration, and course of the school refusal (noted by 11.3%) and the specific triggers of school refusal (noted by 9.9%).</p> <hd id="AN0156413873-14">Discussion</hd> <p>The aim of this study was to explore whether an established questionnaire used to classify reasons for school refusal in neurotypical children has the same factor structure for children on the autism spectrum and whether parents felt that it allowed them to report on all of the factors they feel may be contributing to their child's school refusal. Parent participants reported on the 24 items of the SRAS-R-P and provided feedback as to their perceived relevance to understanding and describing school refusal in children on the spectrum. The findings from reliability and factor analyses indicated that the original four-subscale model is a poor fit for describing reasons for school refusal in the context of autism. The factor analyses indicated that the items may be measuring different factors or traits in children on the autism spectrum than in neurotypical children, suggesting that further work is needed before this scale could have clinical or research utility in this population. Parent feedback suggests that a notable proportion (41.7%) did not feel that the questionnaire was appropriate for exploring school refusal in children on the spectrum and almost 90% of the parents felt that additional questions needed to be asked for the questionnaire to be a useful questionnaire to identify the factors causing or impacting school refusal in children on the spectrum.</p> <p>As this was the first study to explore the SRAS-R-P in a sample of individuals on the autism spectrum, the profile of responses on the SRAS-R-P items was explored. The highest rating scores related to "bad feelings" associated with school and preference for being with parent/family compared to the lowest rating items associated with doing fun activities. This suggests that absenteeism in children on the autism spectrum may be related to the child's worry and concerns about being at school. One factor that has been associated with school refusal in autism is bullying (Bitsika et al., [<reflink idref="bib4" id="ref46">4</reflink>]; McClemont et al., [<reflink idref="bib30" id="ref47">30</reflink>]). Bullying is universally associated with school absenteeism (Baams et al., [<reflink idref="bib3" id="ref48">3</reflink>]; Cornell et al., [<reflink idref="bib9" id="ref49">9</reflink>]) and has been shown to predict school absenteeism due to the child feeling unsafe (Baams et al., [<reflink idref="bib3" id="ref50">3</reflink>]). Bullying is also associated with negative psychological consequences (Zablotsky et al., [<reflink idref="bib46" id="ref51">46</reflink>]). Given that children on the autism spectrum experience bullying more frequently than do their peers (Cappadocia et al., [<reflink idref="bib6" id="ref52">6</reflink>]), addressing the perception of, risk or and/or occurrent of bullying, alongside children's feelings of safety at school may provide a method of reducing school absenteeism and supporting psychological well-being. This could be achieved through improving school connectedness, which encompasses supportive relationships with peers and teachers (Hebron, [<reflink idref="bib17" id="ref53">17</reflink>]) and has been suggested as a protective factor for mental health in students on the spectrum (Shochet et al., [<reflink idref="bib41" id="ref54">41</reflink>]).</p> <p>The results of the factor analysis suggest that the four-factor structure originally posed by Kearney ([<reflink idref="bib22" id="ref55">22</reflink>]) is not applicable for this sample of students on the spectrum, with all model fit statistics suggesting a poor fit. As this was the first exploration of this questionnaire in this population, the full and original SRAS-R-P was administered; however, some authors have recommended removal of Items 20 and 24 as these have more complex wording (Kearney, [<reflink idref="bib23" id="ref56">23</reflink>]). Other authors have reworded questions to remove the comparators, resulting in a better fit (see Heyne et al. ([<reflink idref="bib19" id="ref57">19</reflink>]) for a review of each study's decisions around specific items of the SRAS-R-P). Future work could explore these reworded questions within this population, potentially with the addition of some autism-specific questions informed by the parent responses to the open-questions on additional factors within this study.</p> <p>Clinically, the SRAS-R-P has typically been used to gain a snapshot of motivating factors and has been successfully used to identify treatment approaches, such child-based psychoeducation, cognitive restructuring, and exposure-based practice for those with higher scores on the <emph>Avoidance of stimuli provoking negative affectivity</emph> and <emph>Escape from aversive social and/or evaluative situations</emph> subscales, parent-based contingency management for those with elevated scores on the <emph>Pursuit of attention from others</emph> subscale and family-based contingency contracting for those with high scores in the <emph>Pursuit of tangible reinforcement outside of school</emph> subscale (see discussion in Haight et al., [<reflink idref="bib15" id="ref58">15</reflink>]). Whilst the poor model fit for the SRAS-R-P subscales means that this is not possible at a subscale level for students with autism at present, there is merit in considering what can be learnt about possible treatment approaches on the basis of the items that showed the highest and lowest endorsement within this sample. The three items with the lowest endorsement (i.e. rated as <emph>never</emph> or <emph>seldom</emph> by more than half of the sample and as <emph>almost always</emph> or <emph>always</emph> by less than 7.5% of the sample) were all from the <emph>Pursuit of tangible reinforcement outside of school</emph> subscale. This may suggest that access to tangibles is not a common reinforcer of school refusal within this sample of students on the autism spectrum. Two of the three most endorsed items were from the <emph>Pursuit of attention from others</emph> subscale and one was from the <emph>Avoidance of stimuli provoking negative affect</emph> subscale<emph>.</emph> This finding may suggest that interventions to prevent or reduce school refusal in individuals on the autism spectrum may need to work both with the child, their family members and the school to help the child feel safe and supported within the school setting. Given the feedback from parents in the open-ended question aspect of this study, predictability and accessibility of the built physical environment and student–teacher relationships need to be explored in relation to school refusal in qualitative studies with children and parents, as such findings may help inform treatment approaches and strategies for school refusal in students with autism in the future.</p> <p>As this was the first exploration of this questionnaire in this population, the full and original SRAS-R-P was administered; however, some authors have recommended removal of Items 20 and 24 as these have more complex wording (Kearney, [<reflink idref="bib23" id="ref59">23</reflink>]). Other authors have reworded questions to remove the comparators, resulting in a better fit [see Heyne et al. ([<reflink idref="bib19" id="ref60">19</reflink>]) for a review of each study's decisions around specific items of the SRAS-R-P]. Future work could explore these reworded questions within this population, potentially with the addition of some autism-specific questions informed by the parent responses to the open-questions on additional factors within this study.</p> <p>The importance of obtaining feedback from parents on the relevance and applicability of the SRAS-R-P was highlighted by the significant proportion of parents who noted that the questionnaire was missing questions on specific areas which they felt were important in order to understand their child's school refusal. Although school-related factors are believed to play a role in school refusal in neurotypical children, studies have tended to focus upon child- and family-related causal factors, and consequently, research into school factors has been scarce (Havik et al., [<reflink idref="bib16" id="ref61">16</reflink>]). The two most common factors which parents felt the SRAS-R-P did not cover were both school-related factors: the sensory or school environment (noted by 21.1% of parents) and school knowledge of autism and child-teacher relationship (16.9%). Interestingly, both sensory issues and knowledge of autism were two issues recently highlighted in systematic reviews of barriers to accessing physical (Mason et al., [<reflink idref="bib28" id="ref62">28</reflink>]) and mental healthcare (Adams &amp; Young, [<reflink idref="bib1" id="ref63">1</reflink>]). These two factors have also been previously discussed in relation to school inclusion and participation (Hodges et al., [<reflink idref="bib20" id="ref64">20</reflink>]; Roberts &amp; Simpson, [<reflink idref="bib36" id="ref65">36</reflink>]), as have child-teacher relationships. Additionally, these reviews identified social communication characteristics of students on the spectrum as impacting upon child-teacher relationships and, therefore, school participation and inclusion. It may be that these knowledge-based and environmental aspects could be considered broader contextual factors which combine to make it easier or more challenging for an individual on the spectrum to get to and participate in a specific activity, rather than factors which are specifically linked to school refusal per se. This suggests, then, that contextual factors could be important places to target interventions (both in and outside of the educational context) in order to have the maximum benefit and to show the broadest outcomes.</p> <hd id="AN0156413873-15">Limitations and Future Directions</hd> <p>This study has highlighted the possibility that the function of school refusal in children on the autism spectrum may encompass factors not identified in neurotypical children. These results need to be considered within the limitations of this study. Parents may have limited knowledge about what is actually going on in classrooms and at school, and their experiences are mainly indirect ones, conveyed through interactions with their children and the teachers. However, school refusal does present at home with reluctance or refusal to attend school, so parents are useful informants of school refusal behaviours within that context. There may be a bias in parents' determination of school refusal behaviours, with a tendency to attribute functions to systemic factors. For example, Malcolm et al. ([<reflink idref="bib27" id="ref66">27</reflink>]) showed that parents perceived the main causes for their children's truancy to be bullying, problems with teachers, and pressure from fellow students, while teachers believed that parental attitudes and home environments were the main reasons. Finally, it is acknowledged that this was an online survey, so no direct assessments of autism characteristics nor other factors such as IQ or academic attainment were included, which may influence the profile of scores on the SRAS-R-P. The sample size of 121 is modest for factor analysis, and further exploration of the factor structure of the SRAS-R-P in individuals with autism is recommended with larger sample sizes. Larger samples would also allow for the exploration of factor structure by frequency of school refusal, as it may be that different factor structures are present for those with emerging or established school refusal.</p> <p>The slightly higher (54%) rate of days impacted by school refusal in this sample may reflect the recruitment method; the two previous studies to report on prevalence (Munkhuagen et al., [<reflink idref="bib32" id="ref67">32</reflink>]; Totsika et al., [<reflink idref="bib44" id="ref68">44</reflink>]) both recruited through schools, which means that parents of children not attending school at all due to school refusal are unlikely to receive the recruitment information and therefore unlikely to participate in the study. This highlights the need for future studies to clearly document their recruitment method and to try and use a variety of recruitment methods to capture a sample that is as reflective of the population as possible.</p> <p>The identification of the need to adapt or add to one of the most widely used measures of school refusal, the SRAS-R-P, to make it more useful for children on the autism spectrum is an important step in furthering our understanding on this issue. However, to develop a more comprehensive understanding of the functions of school refusal and therefore develop a more helpful questionnaire, additional studies including the perspectives of children and teachers are needed. Combining qualitative data with quantitative frequency and function data would help to work towards development or tailoring of interventions to reduce school refusal in children on the autism spectrum. Focus groups exploring the questions of the SRAS-R-P with parents as well as adolescents on the autism spectrum may help to identify questions that may cause confusion, are influenced by subjective terms (e.g., "fun") or may indeed reflect multiple functions or factors associated with school refusal. Although a range of psychosocial treatment to address school refusal have been proposed for neurotypical children, no studies have ever evaluated these for children on the autism spectrum. However, before any interventions can be planned or developed, the pathways and factors contributing to the onset and maintenance of school refusal in children on the autism spectrum need to be further explored so that they can inform the potential intervention points.</p> <hd id="AN0156413873-16">Acknowledgments</hd> <p>We are grateful to the children with autism and their families for giving their time to support this research study.</p> <hd id="AN0156413873-17">Auhtor Contributions</hd> <p>DA conceived the study, participated in its design and coordination, coordinated the data cleaning, performed the statistical analysis and interpretation of the data and drafted the manuscript. RM participated in the study design and coordination, assisted with interpretation of the data and drafted the manuscript. HM assisted with interpretation of the data and drafted the manuscript. KS participated in the study design and coordination, assisted with the interpretation of the data and helped draft the manuscript. ND conducted the statistical analysis and interpretation of the CFA and help draft the revisions to the manuscript. All authors read and approved the final manuscript.</p> <hd id="AN0156413873-18">Funding</hd> <p>This research received no specific grant from any external funding agency in the public, commercial, or not-for-profit sectors. There is no external funding associated with this research. The authors acknowledge the support of a small internal seeding grant from Griffith University School of Education and Professional Studies. This work has not been presented at any conference or meeting nor posted on any website, forum, or discussion board.</p> <hd id="AN0156413873-19">Declarations</hd> <p></p> <hd id="AN0156413873-20">Conflict of interest</hd> <p>The authors declare that they have no conflict of interest.</p> <hd id="AN0156413873-21">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0156413873-22"> <title> References </title> <blist> <bibl id="bib1" idref="ref37" type="bt">1</bibl> <bibtext> Adams D, Young J. A systematic review of the perceived barriers and facilitators to accessing psychological treatment for mental health problems in individuals on the autism spectrum. Review Journal of Autism and Developmental Disorder. 2020</bibtext> </blist> <blist> <bibl id="bib2" idref="ref35" type="bt">2</bibl> <bibtext> Adams D, Young K, Simpson K, Keen D. 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| Items | – Name: Title Label: Title Group: Ti Data: Form, Function and Feedback on the School Refusal Assessment Scale--Revised in Children on the Autism Spectrum – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Adams%2C+Dawn%22">Adams, Dawn</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8001-0126">0000-0001-8001-0126</externalLink>)<br /><searchLink fieldCode="AR" term="%22McLucas%2C+Raechel%22">McLucas, Raechel</searchLink><br /><searchLink fieldCode="AR" term="%22Mitchelson%2C+Hayley%22">Mitchelson, Hayley</searchLink><br /><searchLink fieldCode="AR" term="%22Simpson%2C+Kate%22">Simpson, Kate</searchLink><br /><searchLink fieldCode="AR" term="%22Dargue%2C+Nicole%22">Dargue, Nicole</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. May 2022 52(5):2156-2167. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 12 – Name: DatePubCY Label: Publication Date Group: Date Data: 2022 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Audience Label: Education Level Group: Audnce Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink> – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Measures+%28Individuals%29%22">Measures (Individuals)</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Attendance%22">Attendance</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Factor+Analysis%22">Factor Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Usability%22">Usability</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10803-021-05107-4 – Name: ISSN Label: ISSN Group: ISSN Data: 0162-3257 – Name: Abstract Label: Abstract Group: Ab Data: School refusal is more prevalent in children on the autism spectrum than among their peers. The function of school refusal can be explored using the school refusal assessment scale--revised (SRAS-R) but its relevance to children on the spectrum has not been investigated. Parents of 121 children ("M" age 11.9 years) on the autism spectrum completed the SRAS-R and provided feedback on it applicability. Confirmatory factor analysis suggests unsuitability of the original four-factor structure proposed for neurotypical students. Only 41.7% of parents considered the questionnaire an adequate method for reporting on school refusal in children on the autism spectrum with the majority (90%) identifying additional questions to evaluate factors associated with school refusal in autism. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2022 – Name: AN Label: Accession Number Group: ID Data: EJ1333222 |
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