School Anxiety Experienced by Autistic Children: A Systematic Review of Contributing Factors

School Anxiety Experienced by Autistic Children: A Systematic Review of Contributing Factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review School Anxiety Experienced by Autistic Children: A Systematic Review of Contributing Factors Emmie Fisher, Priyanka Rob, Keren MacLennan, Sinéad Mullally, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7711229/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Anxiety about school is becoming increasingly recognised among Autistic learners, yet the term is often applied in essentialist ways that obscure underlying contributors. Our systematic review aimed to identify and evaluate research examining psychosocial contributors to school anxiety among Autistic learners. We included studies which reported a relationship – without attributing it to a non-contributing reason - between school anxiety and a psychosocial factor among Autistic learners. We searched PsycINFO, Medline, ERIC, and Scopus through March 2025. Eight papers (N = 767 participants) met inclusion criteria, including three qualitative and five quantitative studies. We conducted a narrative synthesis and assessed quality using STROBE and CASP. Three studies investigated individual-level factors (e.g., age, gender) with mixed significance. Five identified micro-system level contributors: social expectations ( n = 4), academic and cognitive expectations ( n = 2), and physical design ( n = 4). Using a critical realist lens, we propose a layered ecological framework in which neuro-normative epistemic injustice shapes the micro-system through school-based contributors, or affordances, that manifest as individual differences. Eligible studies were limited in epistemic depth, which overlooked interrelations and deeper macro-systemic mechanisms. Despite generally moderate to high quality, key limitations included reliance on service-based recruitment, underrepresentation of marginalised identities, and dominance of non-Autistic informants – reinforcing epistemic injustice by sidelining Autistic perspectives. Our findings highlight the need for inclusive, participatory methods capable of capturing the complex, macrosystemic realities of Autistic learner’s experiences of school anxiety. Psychology School Anxiety Autism Epistemic Injustice Attendance Neuro-Normativity School Policy Figures Figure 1 Figure 2 Introduction Currently, nearly 1 in 18 Autistic children and young people (CYP) in the United Kingdom (UK) are absent for 50% or more of school – a 189% increase since 2017 (Gov.UK., 2025). Similar patterns are observed internationally, including in the United States (US) and Australia (U.S. Department of Education., 2025; ACARA, 2024 ). A key contributor is the emotional toll of school, particularly anxiety and distress (Adams, 2022 ; Connolly et al., 2023 ). These responses are deeply intertwined with isolation (Ambrose et al., 2024 ), academic challenges (Ambrose et al., 2021 ), low self-esteem (Billington et al., 2024 ), and suicidality (Diogu et al., 2025). Despite the scale of these harms, research on the emotional consequences of school attendance for Autistic CYP remains underdeveloped (Adams et al., 2018 ; Fielding et al., 2025 ). Autistic distress has long been framed through deficit-based behaviourist language contested by Autistic communities – terms like challenging or disruptive behaviour or school refusal – which risk misinterpreting distress as defiance (Bottema-Beutel et al., 2021 ; Bitsika and Sharpley, 2016 ; Adams et al., 2022 ). Such conceptualisations underpin behaviourist interventions aimed at enforcing compliance, including Applied Behaviour Analysis, which penalises underlying Autistic traits and distress (Mansfield and Soni, 2024 ; Poed and Fox, 2023 ; Anderson, 2023 ; Kupferstein, 2018 ). Most concerningly, these deficit-framed interpretations place an essentialist burden on Autistic CYP – deflecting attention from the structural conditions that produce their distress (Jorgensen et al., 2023 ). Such misinterpretations are rooted in dominant knowledge systems that only recognise Neurotypical ways of thinking, communicating, and coping – a form of epistemic injustice (Legault et al., 2021 ; Jorgensen et al., 2023 ). Grounded in neuro-normativity, these systems can only understand Autistic traits as deficits, systematically mispresenting and dismissing Autistic knowledge and experience (Legault et al., 2019 ; Catala et al., 2021 ). As we argue elsewhere (Fisher et al., 2025a ), this injustice manifests within education through neuro-normative affordances: possibilities for action and interaction within a given environment – from macrosystems, or broader norms and policies, to micro-level immediate school environments – which are set up for Neurotypical CYP to more intuitively navigate (see Fig. 1 ; Brofenbrenner, 1994 ; Legault et al., 2019 ; Omodan, 2023 ; Legault et al., 2024 ). Within this landscape, Autistic CYP must expend disproportionate effort to access and respond to educational affordances, creating anxiety (Krueger and Maiese, 2018 ; Fisher et al., 2025a ). For example, teacher understanding constitutes a relational affordance – one that can enable or constrain communication, learning, and wellbeing (Kotzee, 2017 ). However, this is often structured by neuro-normative knowledge systems shaped by epistemic injustice, where teachers lack the frameworks to recognise or meet Autistic needs (Billington et al., 2024 ; Gomez-Mari et al., 2021). When behaviourist framings dominate, Autistic distress is disproportionately less likely to be legitimised or supported (Day, 2025 ; Sproston et al., 2017 ; Kourti, 2021 ). This institutionalised knowledge – itself a neuro-normative affordance - produces widespread exclusionary practices (Blackwell, 2024 ). For example, attendance becomes enforced under the assumption that Autistic CYP won’t attend, rather than can’t (Mullally and Connolly, 2025 ; Fricker, 2023 ). Consequently, approximately 25% of Autistic UK learners have experienced suspension - while families are left to manage the emotional and financial fallout (Tomaskova et al., 2024 ; Goodall, 2019 ; Gray et al., 2023 ; Cleary et al., 2024 ). The terminology and knowledge we construct, therefore, carries tangible implications across education (Omodan, 2023 ). One such term, school anxiety , may more precisely foreground the future-oriented emotional states associated with anticipated negative school experiences - which disproportionately affects Autistic CYP (García-Fernández et al., 2008 ; Adams et al., 2019a ; Connolly et al., 2023 ). It is commonly clustered into generalised, social, and academic anxiety (García-Fernández et al., 2014 ; Lyneham et al., 2008 ; Adams et al., 2018 ). The term is widely used; Adams et al.’s ( 2019a ) systematic review identified 37 studies examining school anxiety in Autistic CYP. More broadly, one in three Autistic CYP experience clinically significant anxiety (Thiele-Swift and Dorstyn, 2024 ). However, much of this research fails to acknowledge context. Instead, anxiety is frequently framed as a stable essentialist characteristic - something the child brings into school where differences are attributed to individual, or internal and within-child, factors - equated to teacher-reported anxiety (Adams et al., 2019a ) or assumed treatable solely through therapy (Reaven et al., 2022; Pilgrim, 2013 ; Bueter, 2019 ). Given that Autistic CYP are disproportionately likely to experience school anxiety (Adams et al., 2019a ), this lack of contextual analysis risks misattributing vulnerability to Autism itself. Some studies position Autistic traits as causal to school anxiety or associated contributors, like victimisation (Junttila et al., 2024 ; Whelan et al., 2021 ). As with terms like challenging behaviour , these framings legitimise essentialist interventions focused on reducing Autistic traits and promoting neuro-normative ‘skills’ – without addressing the environments that produced the anxiety in the first place (Fisher, 2023 ; Chapman & Carel, 2022 ). Meaningfully disentangling school anxiety from generalised anxiety– and from assumptions that it is inherent to Autism or individual children – requires a systematic investigation of its contributors: the factors that trigger and exacerbate it (Fisher et al., 2025a ; Botha, 2021a ). This is also a matter of epistemic injustice, demanding the decentralisation of neuro-normativity within research (Russell and Wilkinson, 2023 ). Only recently – alongside the growing inclusion of Autistic voices - have studies begun to reflect long-standing lived realities: that anxiety is a response to hostile and invalidating micro-level affordances, including sensory environments, curricula, and teacher understanding (Billington et al., 2024 ; Fielding et al., 2025 ; Costley et al., 2021 ; Price & Romualdez, 2025 ; Fisher et al., 2025b ). Without contextual analysis, research continues to narrow understanding of the factors that can change anxiety – risking reductionist interventions with limited success (Clark and Adams, 2020 ; Adams et al., 2018 ; Rodgers & Ofield, 2018 ). Notably, there remains a dearth of research into macrosystemic contributors that shape the micro-system and school anxiety (Fisher et al., 2025b ). From a critical realist perspective, which underpins our review, such interpretations lack epistemic depth by focussing solely on observable phenomena while neglecting underlying causes (Botha, 2021a ; Bhaskhar, 1998). Consequently, interventions risk proving unfeasible or counter-productive by failing to address structural barriers – such as conflicting policies or institutional norms (Williams-Brown et al., 2024 ). Reflecting this, only 9% Autistic CYP report any benefit from mental health support (Ashworth et al., 2025). More recently, some researchers have proposed replacing the term school anxiety with school distress in the hope of fostering greater understanding of the qualia of children’s school lives, earlier recognition of distress and better recognition of systemic drivers of this distress (Connolly et al., 2023 ; Mullally and Connolly, 2025 ; Fielding et al., 2025 ). While promising, school anxiety remains dominant within autism research, thereby warranting critical scrutiny. To date, several systematic reviews have addressed related school-related topics - including the academic consequences of anxiety (Ambrose et al., 2021 ), school-based interventions (Perihan et al., 2023 ), wellbeing (Carroll et al., 2025 ), transitions (Stack et al., 2021 ), and general experiences (Horgan et al., 2023 ) among Autistic CYP – but none have specifically interrogated contributors to school anxiety. This omission is concerning given that anxiety is one of the most reported outcomes of schooling for Autistic CYP - yet far less so among Neurotypical CYP with comparable attendance difficulties (Horgan et al., 2023 ; Connolly et al., 2023 ; Adams et al., 2019a ). Given the conceptual and applied dominance of school anxiety, it is vital we assess how it has been defined, measured, and understood. This has significant implications for support: interventions are likely to remain focussed on the downstream consequences of persistent distress – in symptoms and behaviours - unless they are grounded in an understanding of how , why , and where school anxiety arises. We therefore asked: How is school anxiety measured in Autistic CYP and what assessment tools or informants are used? Which factors or characteristics are proposed to contribute to school anxiety in Autistic CYP? What is the quality of this evidence? Method Our protocol was registered with PROSPERO, an international register of systematic reviews (registration number: CRD42024552410). We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards at all stages of this systematic review (Page et al., 2021). Selection Criteria We included studies if they met the following criteria: (a) the study focussed on Autistic CYP, identified as such by the informant – either as direct participants or as target participants in informant-report data (e.g., parent- or teacher-report); (b) participants were school-age (4–19 years) or enrolled in school; (c) school anxiety was measured using a school anxiety measure, subscale, or qualitative method designed to capture anxiety about school, or via school-based factors identified as contributing to or exacerbating anxiety; (d) contributors were assessed through statistical or thematic relationships between school anxiety and explanatory individual, interpersonal, or contextual factors; (e) for factors to be considered contributors, the original authors either (i) explicitly interpreted them as contributing to increased school anxiety, or (ii) presented them neutrally and descriptively, without at any point explicitly interpreting any as reflecting alternative phenomena (e.g., a psychometric artefact, measurement error, and response bias); (f) constructs entangled with school anxiety — as definitional components or through diagnostic or conceptual overlap (e.g., other anxiety subtypes, attendance, and distress)— were not eligible contributors due to circularity and limited utility in identifying distinct, causal mechanisms; (g) if the study included ineligible additional factors or participants, results relating to Autistic participants, school anxiety, and its contributors were reported separately; and (h) studies had to be empirical, peer reviewed, and published. Only studies published from 1994 onwards were included, corresponding to the introduction of ‘Autism Spectrum Disorder’ within the DSM-IV (American Psychiatric Association, 1994 ). Reviews, opinion pieces, dissertations, brief reports, editorials, conference papers, book chapters, single case studies, case series designs, and studies not published in English were excluded. Criteria (e) and (f) were essential to minimise bias in interpreting non-causal relationships and ensuring a systematic approach. Search Strategy We initially searched the PROSPERO database to ensure no registered systematic reviews addressed the same questions. Following consultation with a medical sciences librarian, we searched PsycINFO, Medline, ERIC, and Scopus in November 2023. To ensure our review remained up to date, we conducted a follow-up search on March 28th 2025. Our strategy combined keywords and controlled vocabulary terms (see Table 1 ), adapted for each database (see supplementary material). We also screened reference lists of included studies, relevant systematic reviews, and the publications of authors of included studies (Adams et al., 2019a ; Ambrose et al., 2021 ). Table 1 Key words for search strategy. Autism Anxiety School Autis*, ASD, ASC, Asperger*, pervasive developmental disorder, PDD Anxi*, mental health, wellbeing, Internali*, distress, stress, worri*, barrier Teacher, school*, educat*, academic, student, pupil, ‘school anxiety’, ‘school refusal’, ‘school avoidance’, ‘school distress’ Note. * was used as a truncation or wildcard symbol in the search strategy. This allows retrieval of any word that begins with the specified root. Terms within each search string were connected by Boolean operator “OR”. Search strings were connected by the Boolean operator “AND”. Review Strategy Our initial database search ( n = 9001) and follow-up search ( n = 1541) returned 10,542 records (see Fig. 2 ), which were imported into Endnote. We identified ten additional records through manual searches using Google Scholar. Following removal of duplicates, all titles and abstracts were screened against the inclusion and exclusion criteria by the lead author (EF). 218 articles were retrieved for full-text screening, of which a random 20% ( n = 44) were independently screened by a second rater (PR). Inter-rater agreement was 100%. All studies meeting inclusion criteria were double rated. Data Extraction and Synthesis Data was extracted by EF and cross-checked by PR under the outcomes defined in the eligibility criteria: research team details, participant and informant characteristics, methods of measuring school anxiety and its contributors, and the contributors identified. No further assumptions were made about missing or ambiguous data. Due to high heterogeneity among eligible studies, we synthesised findings narratively (Popay et al., 2007 ). Our interpretation was guided by a critical realist epistemology, which recognises that both Autism and school anxiety are ontologically real, but that our understandings is shaped by fallible, socially situated knowledge (Kourti, 2021 ; Bhaskar, 1998 ). This lens enabled us to conceptualise findings in relation to underlying mechanisms of neuro-normative epistemic injustice contributing to school anxiety (Botha, 2021a ; Fisher et al., 2025a ). We maintained reflexivity through team discussions and journalling to ensure interpretations were grounded in the data and traceable to included studies (Rosqvist et al., 2023 ). Critical Evaluation To comprehensively assess the included studies, we utilised the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (von Elm et al., 2007 ) for quantitative studies and Critical Appraisal Skills Programme (CASP) checklist for qualitative studies. We assessed mixed-methods studies using both frameworks. STROBE was chosen for its structured yet flexible evaluations of research completeness and transparency (Cuschieri, 2019 ; Adams et al., 2019a ), whilst CASP supported ethical and epistemological evaluation relevant to autism research (Long et al., 2020 ; Kourti, 2021 ). Unlike prior systematic reviews that applied inclusion cut-offs (Adams et al., 2019a ), our approach was inclusive to capture the full scope of existing research. To ensure uniform application across studies, EF and JR first standardised the scoring framework. EF and PR then aligned their understanding of criteria before independently appraising all studies. Initial inter-rater agreement was 84.5%, rising to 100% after resolving discrepancies. We also conducted a supplementary evaluation to evaluate aspects of research quality valued by Autistic communities (Cascio et al., 2020; Bottema-Beutel et al., 2021 ; Janiszewski et al., 2025 ). Our evaluation focused on the (1) involvement of Autistic people in the research process, and (2) use of neuro-affirming language. Specifically, we assessed whether Autistic individuals were involved in study development; whether autism was framed as a pattern of deficits; whether person-first language was used; and whether any outdated terminology (e.g., Asperger’s syndrome ) appeared at any point. We summarised findings descriptively, which did not influence inclusion or formal appraisal scores. Results We found a total of eight studies which met the inclusion criteria, summarised in Table 2. Author (Year), Location Informant (n) Child Age & Gender Co-occurrences % School Eligible Measure & Analysis Eligible Contributors Investigated Quantitative & Mixed Adams et al (2019), Australia Parents ( n = 173) Range 6–13 M (80.3%), F (19.7%) Anxiety Diagnosis (36.4%), Anxiety Medication (15.6%). Mixed (% NR). Demographics, Study-specific Questionnaire, ASC-ASD. Chi-Squared. Non-Significant : Gender Significant : Age Cohort (Older)*** Atkinson et al (2024) , UK CYP ( n = 72) Range 11–16 M (54%), F (46%) Reading age > 8 Mainstream (100%), Secondary (100%). Adapted CAT-Q, ASC-ASD, Simple School Belonging Scale. Correlation, Mediation Analysis. Significant : School Belonging**, Camouflaging** Bermudez et al ( 2015 ), Spain Parents and CYP ( n = 38) Range 8–17 M (94.7%), F (5.3%) Clinical Anxiety 2 (68.4%) NR Demographics, SCARED. Correlation. Non-Significant : Age. Sideropoulos et al ( 2024 ), UK Parents ( n = 25) Mean Age 11 M (72%), F (28%) Co-occurring diagnoses (68%), Clinical Anxiety (44%) 3 Pre-transition: Primary (100%), Mainstream (88%), Special (8%) Post-transition: Secondary (100%), Mainstream (68%), Special (12%) SCAS. Repeated Measures ANOVA. Non-Significant : Primary to Secondary School Transition Syriopoulou-Delli et al ( 2018 ), Greece Teachers ( n = 291) Range 4–25 M (73.5%), F (26.5%) IQ 50–150. Nonverbal (13.7%), Monosyllabic Speech (44%), Developed Speech (42.3%). Clinical Anxiety 1 (49.8%) Primary (93.8%), Secondary (4.1%), Centres of creational occupation (2.1%). Demographics, SAS-TR. Pearson r, Independent samples t-test, Kruskal Wallis test. Non-Significant : Gender; Age. Significant : SAS-TR GA : Higher IQ*** SAS-TR SOA : Higher IQ**; More developed speech*** SAS-TR Total : Higher IQ**; More developed speech** Qualitative & Mixed Clark & Adams ( 2020 ), Australia Parents ( n = 72) Range 5–19 M (70.8%), F (19.2%). Co-occurring diagnoses (83%), Anxiety Diagnosis (55%), ADHD (46%), Language Delay (18%). Mainstream (79%) Special (21%) Study-Specific Questionnaire. CA. Overstimulation, unpredictability, and demands at school : Change, unpredictability, and transitions; Noise, chaos, and overstimulation; Task demands, expectations, and time pressures; Not enough downtime, breaks, or access to quiet spaces. Social communication and personal challenges : Needs are not supported; Social relationship issues and difficulties; Communication and learning difficulties; Stress, burnout and/or fatigue; Fear of failure Costley et al ( 2021 ), UK CYP ( n = 18) Range 12–17 M (61.1%), F (38.9%) Anxiety identified by teacher (100%) Secondary (100%), Mainstream (100%) Semi-Structured Interview. TA. Uncertainty; Assessment; Other People’s Behaviour; Bullying Demands of School : Managing Academic Work and Not Getting into Trouble. Transitioning to Secondary School : Physical Space, Number of People, Change from Primary. Negotiating Social Relationships & Fitting in : Fear of Judgement, Anxiety about saying/doing the wrong thing and causing offence, Avoid Support. Managing Concentration : Noise and Distraction. Pressure of Performance : Test Anxiety, Failure, Presentations. Other Children’s Behaviour : Unpredictability, disruption, breaking rules, physicality (pushing and fighting), isolation, exclusion. Reyes et al ( 2022 ), USA Teachers ( n = 17) & Parents ( n = 23) NR NR NR Semi-Structured Focus Groups. TA. Demands; Social Situations; Role of Political Climate for diverse students. Change : changes in routine. Mainstream Classroom : Sensory experiences, phobias. Intersectional Anxiety : Racism, Politics. Social interactions : class presentation, group project or new peer group. Other children’s behaviour : unpredictability, breaking rules. *Significant at 0.05 level, **Significant at 0.01 level, ***Significant at 0.001 level. Abbreviations CYP = Children & Young People, M = Male, F = Female, TA = Thematic Analysis, CA = Content Analysis, NR = Not Recorded, ASC-ASD = Anxiety Scale for Children with Autism Spectrum Disorder, 1 SAS-TR = School Anxiety Scale-Teacher Rating, 2 SCARED = Screen for Child Anxiety Related Emotional Disorder, 3 SCAS = Spence Children’s Anxiety Scale, CAT-Q = Camouflaging Autistic Traits Questionnaire. Study Characteristics The eight studies were conducted across five countries: Australia ( n = 2), the UK ( n = 3), Greece ( n = 1), Spain ( n = 1), and the US ( n = 1). Publication dates ranged between 2015 to 2024, with most ( n = 7) published after 2019. All employed observational designs, including cross-sectional ( n = 7) and prospective cohort ( n = 1). Five studies explicitly interpreted factors as contributors to school anxiety. The remaining three made no explicit claims about causality but did not attribute the relationship to alternative explanations (e.g., psychometric error), and were, therefore, deemed eligible (Syriopoulou-Delli et al., 2018 ; Bermudez et al., 2015 ; Adams et al., 2019b ). Methodologies included quantitative ( n = 3), qualitative ( n = 2), and mixed-methods ( n = 3) designs. In line with our eligibility criteria, three contributed qualitative data, while five contributed only quantitative data. Sample and Participant Characteristics Quantitative sample sizes ranged from 25 to 291; qualitative from 18 to 72. Three studies employed a single recruitment strategy, whilst five utilised multiple. All recruitment methods necessitated engagement with clinical or governmental support, school enrolment, and/or parental motivation. The most common recruitment sources were schools ( n = 5), followed by social media ( n = 4), clinics ( n = 3), and autism community groups ( n = 3). Informants Four studies adopted a multi-informant approach, though only two included multiple eligible informants. In all studies, the same informants provided data on both school anxiety and its identified contributors. Parents were the most common eligible informants ( n = 5), followed by CYP ( n = 3), and professionals ( n = 2). 70% of the eligible research, therefore, came from non-Autistic, or unspecified, informants. Parent informants ranged from 23 to 173 participants (total n = 331); where reported ( n = 3), 73.7% were mothers. Additionally, those reporting parental education (n = 3); 86.4% had completed tertiary education. CYP informants ( M age = 12.8) ranged from 18 to 72 participants (total n = 128); most were male (70.45%) and attended mainstream schools (71.2%). CYP represented 16.7% of the overall sample. Professional informants ranged from 17 to 291 participants (total n = 308); most were female (82.2%). Only Reyes et al. ( 2022 ) included non-teacher roles, such as psychologists (29.41%) and occupational therapists (5.88%). Child Characteristics One study (Reyes et al., 2022 ) focussed solely on teachers and parents’ perspectives on school anxiety and, thus, did not collect any CYP demographic data. Among the remaining seven studies, 72.3% were male, approximating a 2.6:1 male-to-female ratio. CYP ages spanned 4 to 25 years. A minority (4.8%) were aged 15–25 but still in schools in Greece (Syriopoulou-Delli et al., 2018 ). The mean age across studies was 11.5 years. Only two studies reported ethnicities: of those, 88.4% were White (Atkinson et al., 2024; Sideropoulos et al., 2024 ). IQ and/or verbal ability were reported in two studies, with 37.9% having ‘delayed speech’ (Syriopoulou-Delli et al., 2018 , Clark and Adams, 2020 ). Three studies reported clinical anxiety cutoffs, with 54.1% of participants scoring above threshold. Two reported anxiety diagnoses (45.7%; Adams et al., 2019b ; Clark and Adams, 2020 ), and two reported broader co-occurring diagnoses (75.7%; Clark and Adams, 2020 ; Sideropoulos et al., 2024 ). Only one study (Atkinson et al., 2024) allowed self-identification of autism. The remaining seven required a diagnosis via informant-report (57.1%), documentation (28.6%), and/or formal assessment tools (28.6%). Among four studies reporting school type, 23.5% attended primary, 51% secondary, and one examined the primary to secondary transition (Sideropoulous et al., 2024). Two studies (Atkinson et al., 2024; Costley et al., 2021 ) focussed exclusively on secondary school students. Of five reporting provision, 87% attended mainstream schools, while 8.2% attended specialist provision. Methods of Assessing School Anxiety and Contributors Quantitative Data All five quantitative studies assessed school anxiety and its contributors’ using questionnaires. Two used validated school anxiety scales or subscales: the School Anxiety Scale – Teacher Report (SAS-TR) (Lyneham et al., 2008 ; Syriopoulou-Delli et al., 2018 ), and school anxiety subscale from the Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al., 1999 ; Bermudez et al., 2015 ). One (Adams et al., 2019b ) used a binary question asking parents whether their child was anxious at school. Two studies inferred school anxiety by correlating school-related factors with general anxiety scales: the Anxiety Scale for Children - Autism Spectrum Disorder (ASC-ASD) (Rodgers et al., 2016 ; Atkinson et al., 2024) and Spence Children’s Anxiety Scale (SCAS) (Spence, 1998 ; Sideropoulos et al., 2024 ). Contributors were most commonly assessed via demographic questionnaires ( n = 3). Other tools included the Camouflaging Autistic Traits Questionnaire adapted for the school setting and Simple School Belonging Scale (Atkinson et al., 2024). One study examined anxiety change between primary and secondary school (Sideropoulos et al., 2024 ). Analysis included between-group comparisons ( n = 4), correlational analysis ( n = 3), and one mediation analysis. Qualitative Data All three qualitative studies explored school anxiety and its contributors. Two employed semi-structured interviews or focus groups, using thematic analysis with at least two independent coders to identify key themes (Costley et al., 2021 ; Reyes et al., 2022 ). One (Clark and Adams, 2020 ) used a researcher-designed questionnaire to analyse barriers in managing anxiety at school, analysing parent responses through content analysis. Quality Assessment Three studies were assessed using STROBE (max score = 22), two with CASP (max score = 10), and three with both (Table 3 ). Based on appraisal scores, the highest-quality studies were Atkinson et al. (2024) and Costley et al. ( 2021 ). One study (Bermudez et al., 2015 ) scored below the STROBE cut-off of 12 and should be interpreted with caution (Adams et al., 2019a ; Fortin et al., 2012 ). Table 3 CASP and STROBE Scores of Included Studies. Authors STROBE Score CASP Score Bermudez et al ( 2015 )* 10 - Syriopoulou-Delli et al ( 2018 ) 17 - Adams et al (2019) 16 5 Clark and Adams ( 2020 ) 15 5 Atkinson et al (2024) 19 6 Costley et al ( 2021 ) - 6 Sideropoulos et al ( 2024 ) 15 - Reyes et al ( 2022 ) - 5 Note : * Scores below 12 indicate that conclusions should be interpreted with caution. – indicates the study was not assessed using this tool. STROBE scores ranged from 10 to 19, with a mean of 15.3. Most (83.3%) scored 15 or above, indicating moderate to high quality. All clearly reported participant criteria, study outcomes, and data sources. However, transparency indicators were inconsistently reported: 66.7% failed to report missing data, 50% omitted study dates, and only one reported how study size was determined (Atkinson et al., 2024). CASP scores ranged from 5 to 6 (binary scale: 1 = yes, 0 = no/can’t tell), indicating medium quality. No studies explicitly addressed the research-participant relationship or reflexivity. Ethical considerations were inconsistently reported; while one study (Reyes et al., 2022 ) did not report ethical approval, others did not detail how ethical guidelines were upheld. Beyond checklist assessments, critical reflection on language and framing revealed further quality concerns (Table 4 ). Three studies framed Autism as a disorder of deficits and/or impairments; only two used consistently identity-first language (Atkinson et al., 2024; Sideropoulos et al., 2024 ). One included outdated terminology for Autism (Bermudez et al., 2015 ). Only two studies incorporated community involvement: one adopted co-construction, whilst the other consulted community members (Costley et al., 2021 ; Atkinson et al., 2024). Table 4 Evaluation of Research Studies Using Neuro-Affirming Criteria. Authors Participatory Input Language Used Framed as Deficit Outdated terms Bermudez et al ( 2015 ) None Person-First Yes Yes Syriopoulou-Delli et al ( 2018 ) None Person-First Yes No Adams et al (2019) None Mixed No No Clark and Adams ( 2020 ) None Person-First No No Atkinson et al (2024) Consultation Identity-First No No Costley et al ( 2021 ) Co-Construction Mixed No No Sideropoulos et al ( 2024 ) None Identity-First No No Reyes et al ( 2022 ) None Mixed Yes No Note. “Framed as deficit” indicates whether autism was conceptualised at any point as a disorder or set of impairments. “Outdated terms” includes use of labels such as Asperger’s or high-functioning autism . Contributors Analysed Three studies examined individual-level contributors to school anxiety, while five explored micro-level school factors. Among quantitative studies, three assessed child demographics, including age ( n = 3), gender ( n = 2) and IQ/speech development ( n = 1) (Syriopoulou-Delli et al., 2018 ; Bermudez et al., 2015 ; Adams et al., 2019b ). Two studies with eligible quantitative data examined school-related contributors, including school belonging and camouflaging within school (Atkinson et al., 2024) and the primary-to-secondary school transition (Sideropoulos et al., 2024 ). All three qualitative studies exclusively identified school-related contributors (Costley et al., 2021 ; Reyes et al., 2022 ; Clark and Adams, 2020 ). Individual Contributors Neither of the two studies that examined gender differences reported significant results. Similarly, two of three age-focussed studies found no significant relationship (Syriopoulou-Delli et al., 2018 ; Bermudez et al., 2015 ). However, Adams et al (2019) identified a significant moderate effect, with older CYP (aged 12–13) reported to have higher school anxiety than younger CYP (aged 6–8). Syriopoulou-Delli et al. ( 2018 ) also discovered a significant positive correlation between school anxiety and IQ, both in total scores and across all school anxiety subscales. Additionally, children with ‘well developed’ speech showed the highest school anxiety levels across all subscales - except generalised anxiety - compared to those with monosyllabic or no speech. School Contributors - Neuro-Normative Affordances At the micro-level, five studies identified school-based contributors (Brofenbrenner, 1994 ). We interpret these as neuro-normative affordances – structures and expectations that marginalise those whose needs fall outside dominant norms (Fisher et al., 2025a ). Although the macrosystem was not directly examined within eligible studies, we conceptualise it as underpinned by neuro-normative epistemic injustice, which shapes the school-level affordances experienced. As Clark and Adams ( 2020 ) discovered, when ‘needs are not supported’, school anxiety is worsened. Across the studies, the neuro-normative affordances could be grouped into three domains: social expectations, academic and cognitive demands, and the physical and structural design of school environments. Importantly, these affordances intersect and are co-constructed through wider systems shaped by neuro-normative epistemic injustice – creating layered, compounding contributors to school anxiety for Autistic CYP (Legault et al., 2024 ). Social Expectations Four studies identified implicit social pressures - to communicate and behave in neuro-normative ways to gain safety and acceptance –as contributors to school anxiety. A key contributor to school anxiety was the absence of school belonging – defined as the sense of being accepted, included, and safe to be one’s authentic self. One study examined this relationship directly, revealing a significant negative correlation and direct negative effect between school belonging and anxiety (Atkinson et al., 2024). Notably, reduced school belonging led to increased camouflaging within school – the hiding and adapting of Autistic traits to fit in – thereby increasing anxiety. Overtime, the expectation of negative social outcomes – including social relationship issues and difficulties - became a barrier to school anxiety (Clark and Adams, 2020 ). Costley et al. ( 2021 ) found that social relationships provoked anxiety, due to fear of causing offense or conflict. This anticipatory social fear extended into specific school activities, with Reyes et al. ( 2022 ) reporting that entering new peer groups, participating in group projects, and delivering class presentations were common anxiety triggers. A hostile social environment also heightened anxiety through fear of judgement. CYP worried about saying the wrong thing or being perceived negatively (Costley et al., 2021 ). Notably, this was the only study to identify bullying as a contributor to school anxiety, with students often targeted for visibly deviating from neuro-normative standards - such as attending a support unit. Reyes et al. ( 2022 ) further identified intersectional challenges among those who experienced racism. Finally, a lack of social safety was also influenced by the unpredictable and disruptive behaviours of other students. Both Costley et al. ( 2021 ) and Reyes et al. ( 2022 ) reported that rule-breaking and physical aggression from other CYP heightened school anxiety. Academic and Cognitive Demands Autistic students also faced academic and cognitive expectations - rooted in neuro-normative expectations of what, how, and when students are expected to learn and behave to be academically successful – as contributors to school anxiety (Costley et al., 2021 ; Clark and Adams., 2020). In Clark and Adams ( 2020 ), parents cited several barriers directly tied to these expectations. The most frequently reported barriers were task demands, expectations, and time pressures, followed by communication and learning difficulties, and fear of failure. Costley et al. ( 2021 ) similarly found that academic pressures contributed to anxiety, from everyday classroom tasks – such as answering a question – to more intense stress during formal assessments or exams. Importantly, cognitive pressures extended beyond academic tasks and involved aspects of the ‘hidden curriculum’, including punctuality. These pressures were often exacerbated by difficulties concentrating in class. Physical and Structural Design Four studies identified the physical and structural design of school environments – including spatial layouts, schedules, and environments that scaffold daily school life - as contributors (Clark and Adams., 2020; Reyes et al., 2022 ; Costley et al., 2021 ; Sideropoulos et al., 2024 ). Overwhelming sensory environments were prominent contributors across three qualitative studies (Clark and Adams, 2020 ; Costley et al., 2021 ; Reyes et al., 2022 ). In Clark and Adams ( 2020 ), 62.5% of parents selected “overstimulation, unpredictability and demands at school” as the primary barrier to managing school anxiety, with ‘noise, chaos, and overstimulation’ commonly cited. Similarly, Costley et al ( 2021 ) and Reyes et al ( 2022 ) reported excessive noise in school as a key cause of school anxiety. Large crowded secondary school environments were particularly anxiety evoking, where sensory demands intensified (Costley et al., 2021 ). ‘Not enough downtime, breaks, or access to quiet spaces’, reported by Clark and Adams ( 2020 ), compounded this anxiety by removing opportunities for sensory regulation. Beyond sensory stressors, change, unpredictability, and transitions emerged as key causes of school anxiety (Clark and Adams, 2020 ). Students experienced anxiety in response to unexpected change in routine, unfamiliar social environments, and new teaching staff (Reyes et al., 2022 ; Costley et al., 2021 ). The transition to secondary school was identified by two studies as a contributor. Costley et al ( 2021 ) identified that environmental and structural issues were worsened in secondary school – including sensory overload and uncertainty about what the new environment would entail. However, Sideropoulos et al. ( 2024 ), in a longitudinal study, found no significant change in anxiety scores across the transition. Discussion Our novel systematic review identified and synthesised contributing factors to school anxiety among Autistic CYP. Prioritising contributors is critical to avoid framing anxiety as inherent to Autism and to develop meaningful interventions (Chapman and Carel, 2022 ; Clark and Adams, 2020 ). For example, Adams et al ( 2019a ), applying similar criteria but not focussing on contributors, found 12.5% of studies with a genetic and biologically essentialist focus (Roohi et al., 2009 ; Gadow et al., 2008, 2009, 2010 ). While ‘school anxiety’ is widely explored (Adams et al., 2019a ), only eight studies met our inclusion criteria – indicating essentialist understandings still dominate (Botha, 2021b ). This is striking given elevated anxiety rates and growing recognition of associated school-based contributors among Autistic CYP (Thiele-Swift and Dorstyn, 2024 ; Connolly et al., 2023 ; Clark and Adams, 2020 ). In contrast, contributor reviews among Neurotypical populations with narrower search pools identified 26 studies on teacher-student relationships (Salter et al., 2024 ) and 44 on academic achievement (Brumariu et al., 2023 ). This gap itself reflects neuro-normative epistemic injustice – a macrosystemic context shaping both micro-level and individual experiences (Legault et al., 2019 ; Catala et al., 2021 ; Fisher et al., 2025b ). Yet this macrosystemic context was entirely absent from reviewed studies, revealing limited epistemic depth from a critical realist lens (Botha, 2021a ; Lawani, 2021 ; Brofenbrenner, 1994 ). Critical realism posits a stratified ontology: the empirical (observable experiences), the actual (events that occur irrespective of observation), and the real (causal mechanisms) (Bhaskar, 1998 ). While individual- and micro-level studies offer useful empirical and actual insights, it is only through theorising the macrosystem – situated within the real – that we can understand how these surface patterns are generated and sustained (Wiltshire, 2018 ; Fisher et al., 2025a ). Without this, recommendations risk reinforcing essentialism and committing the epistemic fallacy – conflating complex, stratified phenomena with only what is measurable (Stahmer et al., 2023 ; Brunson et al., 2023 ; Bhaskar, 2008 ). Inconsistencies or non-significant individual-level findings may reflect misalignment between observed variables, like gender and age, and deeper causal mechanisms (Bhaskar, 1998 ; Botha, 2021a ). Even significant findings lack explanatory meaning if confined to the empirical. For example, Syriopoulou-Delli et al. ( 2018 ) reported significant correlations between school anxiety, IQ, and speech ability, but ‘fluent speech’ may simply increase detection of anxiety via neuro-normative measures (Perihan et al., 2023 ). Similarly, age effects may reflect comprehension bias (Adams et al., 2019b ), rather than genuine developmental change (Schiltz and Magnus, 2021 ). In open and complex systems, isolating surface-level variables without interrogating their macrosystemic roots yields tentative and potentially misleading insight (Wiltshire, 2018 ). Five studies explored micro-level contributors, framed here as neuro-normative affordances. These may underlie individual-level differences observed empirically (Bhaskar, 1998 ; Archer, 2003 ); for example, ‘older age’ (Adams et al., 2019b ) may reflect distinct demands associated with secondary school (Costley et al., 2021 ). Though these studies engaged Autistic CYP’s lived experiences, none included macrosystemic theorisation - limiting explanatory power. Only two studies explored academic and cognitive demands – a concerning gap given elevated exam anxiety and fear of failure among Autistic CYP (Wood & Happé, 2023 ; Simpson et al., 2020 ). Similarly, the hidden curriculum—unspoken behavioural norms students are assumed to intuit—appeared in just one study, despite its disproportionate impact (Costley et al., 2021 ; Poed & Fox, 2023 ; Moyse & Porter, 2015 ). None situated these demands within broader macrosystemic contexts such as rigid, neuro-normative academic standards or national curricula, limiting the feasibility of practice suggestions within system constraints (Williams-Brown and Jopling, 2021 ). Future research must interrogate how academic macrosystems contribute to anxiety. Social affordances appeared in four studies, reflecting patterns of bullying, negative peer interactions and identities, and unsafety among Autistic learners (Williams et al., 2019 ; Billington et al., 2024 ; Cohen et al., 2022 ). Camouflaging – adapting or suppressing Autistic traits to meet neuro-normative expectations (Mullally et al., 2024) – was identified in just one study, despite its well-established association with unsafe environments and poor mental health (Atkinson et al., 2024; Howe et al., 2023 ; Chapman et al., 2022 ; Ai et al., 2024 ). Moreover, only one study provided a theoretical lens, framing school belonging - feeling accepted, respected, and included – as central to anxiety (Atkinson et al., 2024). Given emerging evidence that systemic rejection legitimises exclusion (Fisher et al., 2025b ), the absence of macrosystemic analysis signals a pressing gap for future research. Finally, four studies identified physical and structural affordances. School sensory environments are well-documented to cause distress – through sensory overload and disrupted learning (Jones et al., 2020 ; Howe and Stagg, 2016 ; Acker et al., 2018 ) – only three studies directly linked this to school anxiety. Unpredictability – particularly around school transitions - also emerged as a key contributor, with its role in fuelling anxiety well-established in wider literature (Boulter et al., 2014 ; Jenkinson et al., 2020 ; Nuske et al., 2019; Yates et al., 2024 ). Crucially, all studies examined affordances in isolation, detached from their macrosystemic context. This fragmented approach oversimplifies schools as static rather than dynamic, interdependent systems in which anxiety is co-produced by interacting mechanisms (Fielding et al., 2025 ; Fisher et al., 2025b ). Without a macrosystemic lens, research risks reductionism - applying closed-system logic to a complex, open, system – and overlooks systemic inertia (Williams-Brown and Jopling, 2021 ; Fisher et al., 2025a ; Bhaskhar, 1998). Such epistemological limitations may underlie findings like Sideropoulos et al. ( 2024 ), who reported no change in anxiety during school transitions despite multiple interacting mechanisms. To generate meaningful recommendations for policy and practice, future research must move beyond surface correlates to interrogate the deeper macrosystemic drivers of school anxiety (Fisher et al., 2025a ; Brunson et al., 2023 ). Limitations of Existing Research The limitations of reviewed studies reflect not only gaps in what is examined, but whose knowledge is recognised and how it is generated. A key issue is testimonial injustice – the systemic devaluation of Autistic perspectives due to presumed incredibility (Legault et al., 2024 ; Fricker, 2007 ). Non-Autistic informants outnumbered Autistic voices by approximately 2.5:1. Only two studies incorporated Autistic community input; three used deficit-based terminology. Yet, Autistic people are uniquely positioned to access the actual and real domains of their experience (Fletcher-Watson et al., 2021 ; Kourti, 2021 ). Autism is embodied: while a meltdown may be empirically observable, only the Autistic person can understand its internal (actual) experience ( Rosqvist et al., 2023 ). Ethically grounded participatory research is essential to understand macrosystemic factors underlying school anxiety (Russell and Wilkinson, 2023 ). However, no study demonstrated reflexivity regarding the researcher-participant relationship, risking shallow interpretation and missed causal depth (Botha, 2021a ). Intersecting epistemic injustices were also rarely acknowledged (Botha and Gillespie-Lynch, 2022 ; Omodan, 2023 ). All studies recruited via services or schools, and only one allowed self-identification without diagnosis - excluding those most marginalised by school anxiety, including those off-roll, unable to attend, or in diagnostic limbo (Children’s Commissioner, 2024a ; Adams, 2022 ; Connolly et al., 2023 ; Children’s Commissioner, 2024b ). These CYP also face systemic barriers to support, with only one in four receiving support when sought (Doherty et al., 2022 ; Ashworth et al., 2025). Recruitment practices likely compounded participation disparities: male-to-female ratios approached 3:1, reflecting chronic under-identification of Autistic girls (Daniel and Wang, 2023 ; Milner et al., 2024 ). Ethnicity was rarely reported; where it was, White participants were overrepresented, reflecting racial disparities in diagnosis and service access (Lindsay et al., 2025 ; Lovelace et al., 2021 ). Such oversights narrow the epistemic lens, risking partial understandings of school anxiety that neglect intersectional identity-based marginalisation (Reyes et al., 2022 ; Cohen et al., 2022 ). Future research must centre under-represented CYP through participatory and inclusive recruitment (Cascio et al., 2021 ). These shortcomings are rarely within the remit of individual studies, nor are they captured by typical quality assessments. Only one study fell below the STROBE cut-off; the remainder were deemed moderate to high quality. This highlights a deeper hermeneutical injustice – a lack of conceptual tools to recognise, evaluate, and interpret Autistic and intersectional experiences (Catala et al., 2021 ; Fricker, 2007 ). This is evident in the near-exclusive focus on Autistic CYP without intellectual disabilities in mainstream education. Across the field, nearly 80% of studies disproportionately exclude Autistic CYP with intellectual disabilities due to inaccessible methodologies (Catala, 2020 ; Mingins et al., 2021 ; Russell et al., 2019 ). Greater inclusion demands flexible, adaptive methods (Lewis et al., 2023 ) built through epistemic inclusion of Autistic CYP with intersecting marginalisations (Hofmann, 2023 ). Measurement was another site of injustice. Three studies used scales developed for Neurotypical populations (e.g., SCARED and SAS-TR; Lyneham et al., 2008 ; Garcia-Fernandez et al., 2014; Adams et al., 2019a ), embedding neuro-normative assumptions about anxiety expressions (Perihan et al., 2023 ). These measures risk pathologising Autistic traits, overlooking non-neuro-normative expressions, and conflating observable behaviour with presumed internal states - an epistemic fallacy (Brunson et al., 2023 ; Rapaport et al., 2024 ; Schiltz and Magnus, 2021 ; Stern et al., 2014 ). For example, limited speech may be interpreted as social anxiety, despite alignment with Autistic traits within the Autism Quotient (Gupta et al., 2025 ; Lyneham et al., 2008 ; Baron-Cohen et al., 2006 ). In contrast, scales developed for Autistic populations - like the ASC-ASD, used in two studies – better capture anxiety among Autistic CYP (Goulding et al., 2024 ). As highlighted in prior reviews (Perihan et al., 2023 ; Ambrose et al., 2021 ; Adams et al., 2019a ), future research must prioritise the development of measurement tools capable of disentangling Autistic traits from anxiety to evade pathologising narratives. Limitations of our review The internal validity of our review is open to critique. The small number of included studies, combined with high heterogeneity, limited the feasibility and coherence of advanced synthesis methods (Popay et al., 2006). Inter-rater reliability was also not feasible across all stages, increasing vulnerability to human error and subjectivity (Belur et al., 2021 ). Our review is not intended to be generalisable to broader research on negative school experiences among Autistic learners. To ensure conceptual precision and methodological rigour, eligibility criteria were restrictive, excluding studies without an explicit focus on anxiety (Dekkers et al., 2019 ). Terminological inconsistency further complicated this, with several studies examining conceptually overlapping but differently labelled phenomena – including school experiences (Billington et al., 2024 ; Goodall, 2018 ), identity (Cohen et al., 2022 ), wellbeing (Danker et al., 2019 ), emotionally based school avoidance (Hamilton, 2024 ), and inclusion (Lebenhagen, 2024 ). Other Neurodivergent groups, such as ADHD (Mansfield & Soni, 2024 ) and dyslexia (Novita, 2016 ), were also excluded despite frequent diagnostic and experiential co-occurrence (Astle et al., 2022 ). The exclusion of growing literature using the term school distress also limits our scope. We excluded this body of work due to its relative novelty and less established conceptualisation (Connolly et al., 2023 ; Adams et al., 2019a ). While conceptual distinctions remain underdeveloped, it is likely that distress both contributes to, and is shaped by, anxiety. Notably, contributors identified – including poor support, unpredictability, unsafety, sensory distress, and bullying – appear to precede both constructs (Fielding et al., 2025 ; Mullally and Connolly, 2025 ). This presents a central limitation: by narrowing our scope, our review risks replicating the very criticisms levelled at the included studies – fragmentation and limited theoretical depth. As such, while our findings offer a valuable foundation for understanding school anxiety, they must be interpreted with caution and an awareness of these exclusions. Conclusion Our novel review highlights significant gaps in the evidence base on what contributes to school anxiety among Autistic CYP. Despite the term’s widespread use, only eight studies explicitly investigated contributing factors – suggesting its popularity may be shaped by essentialist understandings and longstanding epistemic injustice. Crucially, no studies interrogated the deeper, macrosystemic conditions – rooted in neuro-normative epistemic injustice, and embedded within culture, policies, and dominant knowledge systems – that make school anxiety-evoking for Autistic CYP. These structural conditions produce the identified micro-level hostile social experiences, academic expectations, and structural conditions that may manifest as individual-level differences in school anxiety in IQ, age, and gender. Without theorising macrosystemic context, research offers only superficial insights, leaving effective, feasible interventions out of reach. Most concerningly, current approaches risking reinforcing the assumption that anxiety is inherent to Autism, rather than a product of systemic failure. Future research must urgently expand the field’s epistemic scope. This includes amplifying Autistic voices – particularly those facing intersecting epistemic injustices – and interrogating the macrosystemic context. It also requires moving beyond standardised tools rooted in neuro-normative assumptions, and towards, participatory, inclusive methodologies that centre lived experience. Only through such depth-oriented, epistemically just inquiry can we begin to develop meaningful, implementable interventions that reflect and respond to the lived realities of school anxiety among Autistic CYP. 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International Journal of Developmental Disabilities , 70 (7), 1207-1217. https://doi.org/10.1080/20473869.2023.2170004 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7711229","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":520456916,"identity":"01c00dd6-be40-4048-b2f2-6ebb58f01ffd","order_by":0,"name":"Emmie 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10:49:04","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":324037,"visible":true,"origin":"","legend":"","description":"","filename":"rs77112290structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7711229/v1/b862b981539e8e4cb8622717.xml"},{"id":92252095,"identity":"9f5769f9-c1fd-45d7-af50-160f24132bce","added_by":"auto","created_at":"2025-09-26 10:49:04","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":370882,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7711229/v1/ad2e11eaa83d5d779aafcbea.html"},{"id":92252085,"identity":"e99e8376-44e6-4c99-b2b3-56aadc57a73e","added_by":"auto","created_at":"2025-09-26 10:49:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60567,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eInterpreting School Anxiety through Macrosystemic Neuro-Normative Epistemic Injustice: A Layered Ecological Model of Contributing Factors.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7711229/v1/489624c604067d0557b1eee1.png"},{"id":92252084,"identity":"3f6a9ca8-cd38-4f8e-bd2f-7ba3116c57b4","added_by":"auto","created_at":"2025-09-26 10:49:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56142,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA flow diagram of review process.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7711229/v1/4f3c55a5d9bc8216da8f4742.png"},{"id":92253195,"identity":"ee5c46d2-9d2d-4981-acf7-53e3a906732f","added_by":"auto","created_at":"2025-09-26 11:05:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1898964,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7711229/v1/60528b17-134e-48fc-bcc4-028e2793e6ad.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eSchool Anxiety Experienced by Autistic Children: A Systematic Review of Contributing Factors\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCurrently, nearly 1 in 18 Autistic children and young people (CYP) in the United Kingdom (UK) are absent for 50% or more of school \u0026ndash; a 189% increase since 2017 (Gov.UK., 2025). Similar patterns are observed internationally, including in the United States (US) and Australia (U.S. Department of Education., 2025; ACARA, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A key contributor is the emotional toll of school, particularly anxiety and distress (Adams, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These responses are deeply intertwined with isolation (Ambrose et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), academic challenges (Ambrose et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), low self-esteem (Billington et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and suicidality (Diogu et al., 2025).\u003c/p\u003e\u003cp\u003eDespite the scale of these harms, research on the emotional consequences of school attendance for Autistic CYP remains underdeveloped (Adams et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Fielding et al., \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Autistic distress has long been framed through deficit-based behaviourist language contested by Autistic communities \u0026ndash; terms like \u003cem\u003echallenging or disruptive behaviour\u003c/em\u003e or \u003cem\u003eschool refusal\u003c/em\u003e \u0026ndash; which risk misinterpreting distress as defiance (Bottema-Beutel et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Bitsika and Sharpley, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Such conceptualisations underpin behaviourist interventions aimed at enforcing compliance, including Applied Behaviour Analysis, which penalises underlying Autistic traits and distress (Mansfield and Soni, \u003cspan citationid=\"CR199\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Poed and Fox, \u003cspan citationid=\"CR227\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Anderson, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kupferstein, \u003cspan citationid=\"CR177\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Most concerningly, these deficit-framed interpretations place an essentialist burden on Autistic CYP \u0026ndash; deflecting attention from the structural conditions that produce their distress (Jorgensen et al., \u003cspan citationid=\"CR166\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSuch misinterpretations are rooted in dominant knowledge systems that only recognise Neurotypical ways of thinking, communicating, and coping \u0026ndash; a form of epistemic injustice (Legault et al., \u003cspan citationid=\"CR185\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Jorgensen et al., \u003cspan citationid=\"CR166\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Grounded in neuro-normativity, these systems can only understand Autistic traits as deficits, systematically mispresenting and dismissing Autistic knowledge and experience (Legault et al., \u003cspan citationid=\"CR183\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Catala et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As we argue elsewhere (Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e), this injustice manifests within education through neuro-normative affordances: possibilities for action and interaction within a given environment \u0026ndash; from macrosystems, or broader norms and policies, to micro-level immediate school environments \u0026ndash; which are set up for Neurotypical CYP to more intuitively navigate (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Brofenbrenner, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Legault et al., \u003cspan citationid=\"CR183\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Omodan, \u003cspan citationid=\"CR215\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Legault et al., \u003cspan citationid=\"CR187\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWithin this landscape, Autistic CYP must expend disproportionate effort to access and respond to educational affordances, creating anxiety (Krueger and Maiese, \u003cspan citationid=\"CR175\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e). For example, teacher understanding constitutes a relational affordance \u0026ndash; one that can enable or constrain communication, learning, and wellbeing (Kotzee, \u003cspan citationid=\"CR171\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, this is often structured by neuro-normative knowledge systems shaped by epistemic injustice, where teachers lack the frameworks to recognise or meet Autistic needs (Billington et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Gomez-Mari et al., 2021). When behaviourist framings dominate, Autistic distress is disproportionately less likely to be legitimised or supported (Day, \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Sproston et al., \u003cspan citationid=\"CR263\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Kourti, \u003cspan citationid=\"CR173\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This institutionalised knowledge \u0026ndash; itself a neuro-normative affordance - produces widespread exclusionary practices (Blackwell, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For example, attendance becomes enforced under the assumption that Autistic CYP \u003cem\u003ewon\u0026rsquo;t\u003c/em\u003e attend, rather than \u003cem\u003ecan\u0026rsquo;t\u003c/em\u003e (Mullally and Connolly, \u003cspan citationid=\"CR209\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Fricker, \u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Consequently, approximately 25% of Autistic UK learners have experienced suspension - while families are left to manage the emotional and financial fallout (Tomaskova et al., \u003cspan citationid=\"CR275\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Goodall, \u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Gray et al., \u003cspan citationid=\"CR146\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Cleary et al., \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe terminology and knowledge we construct, therefore, carries tangible implications across education (Omodan, \u003cspan citationid=\"CR215\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). One such term, \u003cem\u003eschool anxiety\u003c/em\u003e, may more precisely foreground the future-oriented emotional states associated with anticipated negative school experiences - which disproportionately affects Autistic CYP (Garc\u0026iacute;a-Fern\u0026aacute;ndez et al., \u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e; Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is commonly clustered into generalised, social, and academic anxiety (Garc\u0026iacute;a-Fern\u0026aacute;ndez et al., \u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lyneham et al., \u003cspan citationid=\"CR197\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The term is widely used; Adams et al.\u0026rsquo;s (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e) systematic review identified 37 studies examining school anxiety in Autistic CYP. More broadly, one in three Autistic CYP experience clinically significant anxiety (Thiele-Swift and Dorstyn, \u003cspan citationid=\"CR273\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, much of this research fails to acknowledge context. Instead, anxiety is frequently framed as a stable essentialist characteristic - something the child brings into school where differences are attributed to individual, or internal and within-child, factors - equated to teacher-reported anxiety (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e) or assumed treatable solely through therapy (Reaven et al., 2022; Pilgrim, \u003cspan citationid=\"CR223\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Bueter, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Given that Autistic CYP are disproportionately likely to experience school anxiety (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), this lack of contextual analysis risks misattributing vulnerability to Autism itself. Some studies position Autistic traits as causal to school anxiety or associated contributors, like victimisation (Junttila et al., \u003cspan citationid=\"CR168\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whelan et al., \u003cspan citationid=\"CR280\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As with terms like \u003cem\u003echallenging behaviour\u003c/em\u003e, these framings legitimise essentialist interventions focused on reducing Autistic traits and promoting neuro-normative \u0026lsquo;skills\u0026rsquo; \u0026ndash; without addressing the environments that produced the anxiety in the first place (Fisher, \u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Chapman \u0026amp; Carel, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMeaningfully disentangling \u003cem\u003eschool anxiety\u003c/em\u003e from generalised anxiety\u0026ndash; and from assumptions that it is inherent to Autism or individual children \u0026ndash; requires a systematic investigation of its contributors: the factors that trigger and exacerbate it (Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e; Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e). This is also a matter of epistemic injustice, demanding the decentralisation of neuro-normativity within research (Russell and Wilkinson, \u003cspan citationid=\"CR247\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Only recently \u0026ndash; alongside the growing inclusion of Autistic voices - have studies begun to reflect long-standing lived realities: that anxiety is a response to hostile and invalidating micro-level affordances, including sensory environments, curricula, and teacher understanding (Billington et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Fielding et al., \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Price \u0026amp; Romualdez, \u003cspan citationid=\"CR231\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithout contextual analysis, research continues to narrow understanding of the factors that can change anxiety \u0026ndash; risking reductionist interventions with limited success (Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Rodgers \u0026amp; Ofield, \u003cspan citationid=\"CR239\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Notably, there remains a dearth of research into macrosystemic contributors that shape the micro-system and school anxiety (Fisher et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e). From a critical realist perspective, which underpins our review, such interpretations lack epistemic depth by focussing solely on observable phenomena while neglecting underlying causes (Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e; Bhaskhar, 1998). Consequently, interventions risk proving unfeasible or counter-productive by failing to address structural barriers \u0026ndash; such as conflicting policies or institutional norms (Williams-Brown et al., \u003cspan citationid=\"CR286\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Reflecting this, only 9% Autistic CYP report any benefit from mental health support (Ashworth et al., 2025).\u003c/p\u003e\u003cp\u003eMore recently, some researchers have proposed replacing the term \u003cem\u003eschool anxiety\u003c/em\u003e with \u003cem\u003eschool distress\u003c/em\u003e in the hope of fostering greater understanding of the qualia of children\u0026rsquo;s school lives, earlier recognition of distress and better recognition of systemic drivers of this distress (Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mullally and Connolly, \u003cspan citationid=\"CR209\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Fielding et al., \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). While promising, \u003cem\u003eschool anxiety\u003c/em\u003e remains dominant within autism research, thereby warranting critical scrutiny. To date, several systematic reviews have addressed related school-related topics - including the academic consequences of anxiety (Ambrose et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), school-based interventions (Perihan et al., \u003cspan citationid=\"CR219\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), wellbeing (Carroll et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), transitions (Stack et al., \u003cspan citationid=\"CR265\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and general experiences (Horgan et al., \u003cspan citationid=\"CR154\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) among Autistic CYP \u0026ndash; but none have specifically interrogated contributors to school anxiety. This omission is concerning given that anxiety is one of the most reported outcomes of schooling for Autistic CYP - yet far less so among Neurotypical CYP with comparable attendance difficulties (Horgan et al., \u003cspan citationid=\"CR154\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven the conceptual and applied dominance of school anxiety, it is vital we assess how it has been defined, measured, and understood. This has significant implications for support: interventions are likely to remain focussed on the downstream consequences of persistent distress \u0026ndash; in symptoms and behaviours - unless they are grounded in an understanding of \u003cem\u003ehow\u003c/em\u003e, \u003cem\u003ewhy\u003c/em\u003e, and \u003cem\u003ewhere\u003c/em\u003e school anxiety arises. We therefore asked:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow is school anxiety measured in Autistic CYP and what assessment tools or informants are used?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhich factors or characteristics are proposed to contribute to school anxiety in Autistic CYP? What is the quality of this evidence?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e Our protocol was registered with PROSPERO, an international register of systematic reviews (registration number: CRD42024552410). We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards at all stages of this systematic review (Page et al., 2021).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSelection Criteria\u003c/h2\u003e\u003cp\u003eWe included studies if they met the following criteria: (a) the study focussed on Autistic CYP, identified as such by the informant \u0026ndash; either as direct participants or as target participants in informant-report data (e.g., parent- or teacher-report); (b) participants were school-age (4\u0026ndash;19 years) or enrolled in school; (c) school anxiety was measured using a school anxiety measure, subscale, or qualitative method designed to capture anxiety about school, or via school-based factors identified as contributing to or exacerbating anxiety; (d) contributors were assessed through statistical or thematic relationships between school anxiety and explanatory individual, interpersonal, or contextual factors; (e) for factors to be considered contributors, the original authors either (i) explicitly interpreted them as contributing to increased school anxiety, or (ii) presented them neutrally and descriptively, without at any point explicitly interpreting any as reflecting alternative phenomena (e.g., a psychometric artefact, measurement error, and response bias); (f) constructs entangled with school anxiety \u0026mdash; as definitional components or through diagnostic or conceptual overlap (e.g., other anxiety subtypes, attendance, and distress)\u0026mdash; were not eligible contributors due to circularity and limited utility in identifying distinct, causal mechanisms; (g) if the study included ineligible additional factors or participants, results relating to Autistic participants, school anxiety, and its contributors were reported separately; and (h) studies had to be empirical, peer reviewed, and published.\u003c/p\u003e\u003cp\u003eOnly studies published from 1994 onwards were included, corresponding to the introduction of \u0026lsquo;Autism Spectrum Disorder\u0026rsquo; within the DSM-IV (American Psychiatric Association, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). Reviews, opinion pieces, dissertations, brief reports, editorials, conference papers, book chapters, single case studies, case series designs, and studies not published in English were excluded. Criteria (e) and (f) were essential to minimise bias in interpreting non-causal relationships and ensuring a systematic approach.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eWe initially searched the PROSPERO database to ensure no registered systematic reviews addressed the same questions. Following consultation with a medical sciences librarian, we searched PsycINFO, Medline, ERIC, and Scopus in November 2023. To ensure our review remained up to date, we conducted a follow-up search on March 28th 2025. Our strategy combined keywords and controlled vocabulary terms (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), adapted for each database (see supplementary material). We also screened reference lists of included studies, relevant systematic reviews, and the publications of authors of included studies (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e; Ambrose et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eKey words for search strategy.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutism\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSchool\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutis*, ASD, ASC, Asperger*, pervasive developmental disorder, PDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnxi*, mental health, wellbeing, Internali*, distress, stress, worri*, barrier\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeacher, school*, educat*, academic, student, pupil, \u0026lsquo;school anxiety\u0026rsquo;, \u0026lsquo;school refusal\u0026rsquo;, \u0026lsquo;school avoidance\u0026rsquo;, \u0026lsquo;school distress\u0026rsquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote.\u003c/em\u003e * was used as a truncation or wildcard symbol in the search strategy. This allows retrieval of any word that begins with the specified root. Terms within each search string were connected by Boolean operator \u0026ldquo;OR\u0026rdquo;. Search strings were connected by the Boolean operator \u0026ldquo;AND\u0026rdquo;.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eReview Strategy\u003c/h3\u003e\n\u003cp\u003eOur initial database search (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9001) and follow-up search (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1541) returned 10,542 records (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which were imported into Endnote. We identified ten additional records through manual searches using Google Scholar. Following removal of duplicates, all titles and abstracts were screened against the inclusion and exclusion criteria by the lead author (EF). 218 articles were retrieved for full-text screening, of which a random 20% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;44) were independently screened by a second rater (PR). Inter-rater agreement was 100%. All studies meeting inclusion criteria were double rated.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eData Extraction and Synthesis\u003c/h3\u003e\n\u003cp\u003eData was extracted by EF and cross-checked by PR under the outcomes defined in the eligibility criteria: research team details, participant and informant characteristics, methods of measuring school anxiety and its contributors, and the contributors identified. No further assumptions were made about missing or ambiguous data.\u003c/p\u003e\u003cp\u003eDue to high heterogeneity among eligible studies, we synthesised findings narratively (Popay et al., \u003cspan citationid=\"CR229\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Our interpretation was guided by a critical realist epistemology, which recognises that both Autism and school anxiety are ontologically real, but that our understandings is shaped by fallible, socially situated knowledge (Kourti, \u003cspan citationid=\"CR173\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Bhaskar, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). This lens enabled us to conceptualise findings in relation to underlying mechanisms of neuro-normative epistemic injustice contributing to school anxiety (Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e). We maintained reflexivity through team discussions and journalling to ensure interpretations were grounded in the data and traceable to included studies (Rosqvist et al., \u003cspan citationid=\"CR245\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCritical Evaluation\u003c/h3\u003e\n\u003cp\u003eTo comprehensively assess the included studies, we utilised the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (von Elm et al., \u003cspan citationid=\"CR279\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) for quantitative studies and Critical Appraisal Skills Programme (CASP) checklist for qualitative studies. We assessed mixed-methods studies using both frameworks.\u003c/p\u003e\u003cp\u003eSTROBE was chosen for its structured yet flexible evaluations of research completeness and transparency (Cuschieri, \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), whilst CASP supported ethical and epistemological evaluation relevant to autism research (Long et al., \u003cspan citationid=\"CR193\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kourti, \u003cspan citationid=\"CR173\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Unlike prior systematic reviews that applied inclusion cut-offs (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), our approach was inclusive to capture the full scope of existing research.\u003c/p\u003e\u003cp\u003eTo ensure uniform application across studies, EF and JR first standardised the scoring framework. EF and PR then aligned their understanding of criteria before independently appraising all studies. Initial inter-rater agreement was 84.5%, rising to 100% after resolving discrepancies.\u003c/p\u003e\u003cp\u003eWe also conducted a supplementary evaluation to evaluate aspects of research quality valued by Autistic communities (Cascio et al., 2020; Bottema-Beutel et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Janiszewski et al., \u003cspan citationid=\"CR160\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Our evaluation focused on the (1) involvement of Autistic people in the research process, and (2) use of neuro-affirming language. Specifically, we assessed whether Autistic individuals were involved in study development; whether autism was framed as a pattern of deficits; whether person-first language was used; and whether any outdated terminology (e.g., \u003cem\u003eAsperger\u0026rsquo;s syndrome\u003c/em\u003e) appeared at any point. We summarised findings descriptively, which did not influence inclusion or formal appraisal scores.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe found a total of eight studies which met the inclusion criteria, summarised in Table\u0026nbsp;2.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor (Year), Location\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInformant (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChild Age \u0026amp; Gender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCo-occurrences\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% School\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEligible Measure \u0026amp; Analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEligible Contributors Investigated\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuantitative \u0026amp; Mixed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdams et al (2019), Australia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eParents\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;173)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 6\u0026ndash;13\u003c/p\u003e\u003cp\u003eM (80.3%), F (19.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnxiety Diagnosis (36.4%), Anxiety Medication (15.6%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMixed (% NR).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDemographics, Study-specific Questionnaire,\u003c/p\u003e\u003cp\u003eASC-ASD.\u003c/p\u003e\u003cp\u003eChi-Squared.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNon-Significant\u003c/span\u003e: Gender\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSignificant\u003c/span\u003e: Age Cohort (Older)***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAtkinson et al (2024)\u003c/b\u003e,\u003c/p\u003e\u003cp\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCYP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(\u003c/b\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 11\u0026ndash;16\u003c/p\u003e\u003cp\u003eM (54%), F (46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReading age\u0026thinsp;\u0026gt;\u0026thinsp;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMainstream (100%), Secondary (100%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdapted CAT-Q,\u003c/p\u003e\u003cp\u003eASC-ASD,\u003c/p\u003e\u003cp\u003eSimple School Belonging Scale.\u003c/p\u003e\u003cp\u003eCorrelation, Mediation Analysis.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSignificant\u003c/span\u003e: School Belonging**, Camouflaging**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBermudez et al (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), \u003cb\u003eSpain\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eParents and CYP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 8\u0026ndash;17\u003c/p\u003e\u003cp\u003eM (94.7%), F (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClinical Anxiety\u003csup\u003e2\u003c/sup\u003e (68.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDemographics, SCARED.\u003c/p\u003e\u003cp\u003eCorrelation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNon-Significant\u003c/span\u003e: Age.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSideropoulos et al (\u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e),\u003c/p\u003e\u003cp\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eParents\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean Age 11\u003c/p\u003e\u003cp\u003eM (72%), F (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCo-occurring diagnoses (68%), Clinical Anxiety (44%)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePre-transition: Primary (100%), Mainstream (88%), Special (8%)\u003c/p\u003e\u003cp\u003ePost-transition: Secondary (100%), Mainstream (68%), Special (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSCAS.\u003c/p\u003e\u003cp\u003eRepeated Measures ANOVA.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNon-Significant\u003c/span\u003e: Primary to Secondary School Transition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSyriopoulou-Delli et al (\u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), \u003cb\u003eGreece\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTeachers\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;291)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 4\u0026ndash;25\u003c/p\u003e\u003cp\u003eM (73.5%), F (26.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQ 50\u0026ndash;150. Nonverbal (13.7%), Monosyllabic Speech (44%), Developed Speech (42.3%).\u003c/p\u003e\u003cp\u003eClinical Anxiety\u003csup\u003e1\u003c/sup\u003e (49.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary (93.8%), Secondary (4.1%), Centres of creational occupation (2.1%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDemographics, SAS-TR.\u003c/p\u003e\u003cp\u003ePearson r,\u003c/p\u003e\u003cp\u003eIndependent samples t-test,\u003c/p\u003e\u003cp\u003eKruskal Wallis test.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNon-Significant\u003c/span\u003e: Gender; Age.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSignificant\u003c/span\u003e: \u003cb\u003eSAS-TR GA\u003c/b\u003e: Higher IQ***\u003c/p\u003e\u003cp\u003e\u003cb\u003eSAS-TR SOA\u003c/b\u003e: Higher IQ**; More developed speech***\u003c/p\u003e\u003cp\u003e\u003cb\u003eSAS-TR Total\u003c/b\u003e: Higher IQ**; More developed speech**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQualitative \u0026amp; Mixed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClark \u0026amp; Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e\u003cb\u003e), Australia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eParents\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 5\u0026ndash;19\u003c/p\u003e\u003cp\u003eM (70.8%), F (19.2%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCo-occurring diagnoses (83%), Anxiety Diagnosis (55%), ADHD (46%), Language Delay (18%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMainstream (79%)\u003c/p\u003e\u003cp\u003eSpecial (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStudy-Specific Questionnaire.\u003c/p\u003e\u003cp\u003eCA.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eOverstimulation, unpredictability, and demands at school\u003c/b\u003e: Change, unpredictability, and transitions; Noise, chaos, and overstimulation; Task demands, expectations, and time pressures; Not enough downtime, breaks, or access to quiet spaces.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSocial communication and personal challenges\u003c/b\u003e: Needs are not supported; Social relationship issues and difficulties; Communication and learning difficulties; Stress, burnout and/or fatigue; Fear of failure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCostley et al (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), \u003cb\u003eUK\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCYP\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange 12\u0026ndash;17\u003c/p\u003e\u003cp\u003eM (61.1%), F (38.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnxiety identified by teacher (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary (100%), Mainstream (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSemi-Structured Interview.\u003c/p\u003e\u003cp\u003eTA.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eUncertainty; Assessment; Other People\u0026rsquo;s Behaviour; Bullying\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDemands of School\u003c/b\u003e: Managing Academic Work and Not Getting into Trouble.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTransitioning to Secondary School\u003c/b\u003e: Physical Space, Number of People, Change from Primary.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNegotiating Social Relationships \u0026amp; Fitting in\u003c/b\u003e: Fear of Judgement, Anxiety about saying/doing the wrong thing and causing offence, Avoid Support.\u003c/p\u003e\u003cp\u003e\u003cb\u003eManaging Concentration\u003c/b\u003e: Noise and Distraction.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePressure of Performance\u003c/b\u003e: Test Anxiety, Failure, Presentations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOther Children\u0026rsquo;s Behaviour\u003c/b\u003e: Unpredictability, disruption, breaking rules, physicality (pushing and fighting), isolation, exclusion.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReyes et al (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), \u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTeachers\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17) \u0026amp; \u003cb\u003eParents\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSemi-Structured Focus Groups.\u003c/p\u003e\u003cp\u003eTA.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eDemands; Social Situations; Role of Political Climate for diverse students.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eChange\u003c/b\u003e: changes in routine.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMainstream Classroom\u003c/b\u003e: Sensory experiences, phobias.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntersectional Anxiety\u003c/b\u003e: Racism, Politics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSocial interactions\u003c/b\u003e: class presentation, group project or new peer group.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOther children\u0026rsquo;s behaviour\u003c/b\u003e: unpredictability, breaking rules.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Significant at 0.05 level, **Significant at 0.01 level, ***Significant at 0.001 level. Abbreviations CYP\u0026thinsp;=\u0026thinsp;Children \u0026amp; Young People, M\u0026thinsp;=\u0026thinsp;Male, F\u0026thinsp;=\u0026thinsp;Female, TA\u0026thinsp;=\u0026thinsp;Thematic Analysis, CA\u0026thinsp;=\u0026thinsp;Content Analysis, NR\u0026thinsp;=\u0026thinsp;Not Recorded, ASC-ASD\u0026thinsp;=\u0026thinsp;Anxiety Scale for Children with Autism Spectrum Disorder, \u003csup\u003e1\u003c/sup\u003eSAS-TR\u0026thinsp;=\u0026thinsp;School Anxiety Scale-Teacher Rating, \u003csup\u003e2\u003c/sup\u003eSCARED = Screen for Child Anxiety Related Emotional Disorder, \u003csup\u003e3\u003c/sup\u003eSCAS = Spence Children\u0026rsquo;s Anxiety Scale, CAT-Q\u0026thinsp;=\u0026thinsp;Camouflaging Autistic Traits Questionnaire.\u003c/p\u003e\n\u003ch3\u003eStudy Characteristics\u003c/h3\u003e\n\u003cp\u003eThe eight studies were conducted across five countries: Australia (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), the UK (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), Greece (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1), Spain (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1), and the US (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1). Publication dates ranged between 2015 to 2024, with most (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;7) published after 2019. All employed observational designs, including cross-sectional (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;7) and prospective cohort (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003eFive studies explicitly interpreted factors as contributors to school anxiety. The remaining three made no explicit claims about causality but did not attribute the relationship to alternative explanations (e.g., psychometric error), and were, therefore, deemed eligible (Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMethodologies included quantitative (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3), qualitative (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;2), and mixed-methods (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3) designs. In line with our eligibility criteria, three contributed qualitative data, while five contributed only quantitative data.\u003c/p\u003e\n\u003ch3\u003eSample and Participant Characteristics\u003c/h3\u003e\n\u003cp\u003eQuantitative sample sizes ranged from 25 to 291; qualitative from 18 to 72. Three studies employed a single recruitment strategy, whilst five utilised multiple. All recruitment methods necessitated engagement with clinical or governmental support, school enrolment, and/or parental motivation. The most common recruitment sources were schools (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), followed by social media (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), clinics (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), and autism community groups (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInformants\u003c/h2\u003e\u003cp\u003eFour studies adopted a multi-informant approach, though only two included multiple eligible informants. In all studies, the same informants provided data on both school anxiety and its identified contributors. Parents were the most common eligible informants (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;5), followed by CYP (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3), and professionals (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;2). 70% of the eligible research, therefore, came from non-Autistic, or unspecified, informants.\u003c/p\u003e\u003cp\u003eParent informants ranged from 23 to 173 participants (total n\u0026thinsp;=\u0026thinsp;331); where reported (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3), 73.7% were mothers. Additionally, those reporting parental education (n\u0026thinsp;=\u0026thinsp;3); 86.4% had completed tertiary education. CYP informants (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e=\u003c/em\u003e 12.8) ranged from 18 to 72 participants (total n\u0026thinsp;=\u0026thinsp;128); most were male (70.45%) and attended mainstream schools (71.2%). CYP represented 16.7% of the overall sample. Professional informants ranged from 17 to 291 participants (total n\u0026thinsp;=\u0026thinsp;308); most were female (82.2%). Only Reyes et al. (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) included non-teacher roles, such as psychologists (29.41%) and occupational therapists (5.88%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eChild Characteristics\u003c/h2\u003e\u003cp\u003eOne study (Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) focussed solely on teachers and parents\u0026rsquo; perspectives on school anxiety and, thus, did not collect any CYP demographic data. Among the remaining seven studies, 72.3% were male, approximating a 2.6:1 male-to-female ratio.\u003c/p\u003e\u003cp\u003eCYP ages spanned 4 to 25 years. A minority (4.8%) were aged 15\u0026ndash;25 but still in schools in Greece (Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The mean age across studies was 11.5 years. Only two studies reported ethnicities: of those, 88.4% were White (Atkinson et al., 2024; Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). IQ and/or verbal ability were reported in two studies, with 37.9% having \u0026lsquo;delayed speech\u0026rsquo; (Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThree studies reported clinical anxiety cutoffs, with 54.1% of participants scoring above threshold. Two reported anxiety diagnoses (45.7%; Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e; Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and two reported broader co-occurring diagnoses (75.7%; Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Only one study (Atkinson et al., 2024) allowed self-identification of autism. The remaining seven required a diagnosis via informant-report (57.1%), documentation (28.6%), and/or formal assessment tools (28.6%).\u003c/p\u003e\u003cp\u003eAmong four studies reporting school type, 23.5% attended primary, 51% secondary, and one examined the primary to secondary transition (Sideropoulous et al., 2024). Two studies (Atkinson et al., 2024; Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) focussed exclusively on secondary school students. Of five reporting provision, 87% attended mainstream schools, while 8.2% attended specialist provision.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eMethods of Assessing School Anxiety and Contributors\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eQuantitative Data\u003c/h2\u003e\u003cp\u003eAll five quantitative studies assessed school anxiety and its contributors\u0026rsquo; using questionnaires. Two used validated school anxiety scales or subscales: the School Anxiety Scale \u0026ndash; Teacher Report (SAS-TR) (Lyneham et al., \u003cspan citationid=\"CR197\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and school anxiety subscale from the Screen for Child Anxiety Related Disorders (SCARED) (Birmaher et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). One (Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e) used a binary question asking parents whether their child was anxious at school.\u003c/p\u003e\u003cp\u003eTwo studies inferred school anxiety by correlating school-related factors with general anxiety scales: the Anxiety Scale for Children - Autism Spectrum Disorder (ASC-ASD) (Rodgers et al., \u003cspan citationid=\"CR241\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Atkinson et al., 2024) and Spence Children\u0026rsquo;s Anxiety Scale (SCAS) (Spence, \u003cspan citationid=\"CR261\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eContributors were most commonly assessed via demographic questionnaires (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3). Other tools included the Camouflaging Autistic Traits Questionnaire adapted for the school setting and Simple School Belonging Scale (Atkinson et al., 2024). One study examined anxiety change between primary and secondary school (Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnalysis included between-group comparisons (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;4), correlational analysis (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), and one mediation analysis.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Data\u003c/h2\u003e\u003cp\u003eAll three qualitative studies explored school anxiety and its contributors. Two employed semi-structured interviews or focus groups, using thematic analysis with at least two independent coders to identify key themes (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). One (Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) used a researcher-designed questionnaire to analyse barriers in managing anxiety at school, analysing parent responses through content analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eQuality Assessment\u003c/h2\u003e\u003cp\u003eThree studies were assessed using STROBE (max score\u0026thinsp;=\u0026thinsp;22), two with CASP (max score\u0026thinsp;=\u0026thinsp;10), and three with both (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Based on appraisal scores, the highest-quality studies were Atkinson et al. (2024) and Costley et al. (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). One study (Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) scored below the STROBE cut-off of 12 and should be interpreted with caution (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e; Fortin et al., \u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCASP and STROBE Scores of Included Studies.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSTROBE Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCASP Score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBermudez et al (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSyriopoulou-Delli et al (\u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdams et al (2019)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtkinson et al (2024)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCostley et al (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSideropoulos et al (\u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReyes et al (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote\u003c/em\u003e: *\u003cem\u003eScores below 12 indicate that conclusions should be interpreted with caution. \u0026ndash; indicates the study was not assessed using this tool.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSTROBE scores ranged from 10 to 19, with a mean of 15.3. Most (83.3%) scored 15 or above, indicating moderate to high quality. All clearly reported participant criteria, study outcomes, and data sources. However, transparency indicators were inconsistently reported: 66.7% failed to report missing data, 50% omitted study dates, and only one reported how study size was determined (Atkinson et al., 2024).\u003c/p\u003e\u003cp\u003eCASP scores ranged from 5 to 6 (binary scale: 1\u0026thinsp;=\u0026thinsp;yes, 0\u0026thinsp;=\u0026thinsp;no/can\u0026rsquo;t tell), indicating medium quality. No studies explicitly addressed the research-participant relationship or reflexivity. Ethical considerations were inconsistently reported; while one study (Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) did not report ethical approval, others did not detail how ethical guidelines were upheld.\u003c/p\u003e\u003cp\u003eBeyond checklist assessments, critical reflection on language and framing revealed further quality concerns (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Three studies framed Autism as a disorder of deficits and/or impairments; only two used consistently identity-first language (Atkinson et al., 2024; Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). One included outdated terminology for Autism (Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Only two studies incorporated community involvement: one adopted co-construction, whilst the other consulted community members (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Atkinson et al., 2024).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eEvaluation of Research Studies Using Neuro-Affirming Criteria.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipatory Input\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLanguage Used\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFramed as Deficit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOutdated terms\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBermudez et al (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerson-First\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSyriopoulou-Delli et al (\u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerson-First\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdams et al (2019)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerson-First\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtkinson et al (2024)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsultation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIdentity-First\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCostley et al (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCo-Construction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSideropoulos et al (\u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIdentity-First\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReyes et al (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u0026ldquo;Framed as deficit\u0026rdquo; indicates whether autism was conceptualised at any point as a disorder or set of impairments. \u0026ldquo;Outdated terms\u0026rdquo; includes use of labels such as \u003cem\u003eAsperger\u0026rsquo;s\u003c/em\u003e or \u003cem\u003ehigh-functioning autism\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eContributors Analysed\u003c/h2\u003e\u003cp\u003eThree studies examined individual-level contributors to school anxiety, while five explored micro-level school factors. Among quantitative studies, three assessed child demographics, including age (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3), gender (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;2) and IQ/speech development (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1) (Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTwo studies with eligible quantitative data examined school-related contributors, including school belonging and camouflaging within school (Atkinson et al., 2024) and the primary-to-secondary school transition (Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). All three qualitative studies exclusively identified school-related contributors (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eIndividual Contributors\u003c/h2\u003e\u003cp\u003eNeither of the two studies that examined gender differences reported significant results. Similarly, two of three age-focussed studies found no significant relationship (Syriopoulou-Delli et al., \u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Bermudez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, Adams et al (2019) identified a significant moderate effect, with older CYP (aged 12\u0026ndash;13) reported to have higher school anxiety than younger CYP (aged 6\u0026ndash;8). Syriopoulou-Delli et al. (\u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) also discovered a significant positive correlation between school anxiety and IQ, both in total scores and across all school anxiety subscales. Additionally, children with \u0026lsquo;well developed\u0026rsquo; speech showed the highest school anxiety levels across all subscales - except generalised anxiety - compared to those with monosyllabic or no speech.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eSchool Contributors - Neuro-Normative Affordances\u003c/h2\u003e\u003cp\u003eAt the micro-level, five studies identified school-based contributors (Brofenbrenner, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). We interpret these as neuro-normative affordances \u0026ndash; structures and expectations that marginalise those whose needs fall outside dominant norms (Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e). Although the macrosystem was not directly examined within eligible studies, we conceptualise it as underpinned by neuro-normative epistemic injustice, which shapes the school-level affordances experienced. As Clark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) discovered, when \u0026lsquo;needs are not supported\u0026rsquo;, school anxiety is worsened.\u003c/p\u003e\u003cp\u003eAcross the studies, the neuro-normative affordances could be grouped into three domains: social expectations, academic and cognitive demands, and the physical and structural design of school environments. Importantly, these affordances intersect and are co-constructed through wider systems shaped by neuro-normative epistemic injustice \u0026ndash; creating layered, compounding contributors to school anxiety for Autistic CYP (Legault et al., \u003cspan citationid=\"CR187\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eSocial Expectations\u003c/h2\u003e\u003cp\u003eFour studies identified implicit social pressures - to communicate and behave in neuro-normative ways to gain safety and acceptance \u0026ndash;as contributors to school anxiety. A key contributor to school anxiety was the absence of school belonging \u0026ndash; defined as the sense of being accepted, included, and safe to be one\u0026rsquo;s authentic self. One study examined this relationship directly, revealing a significant negative correlation and direct negative effect between school belonging and anxiety (Atkinson et al., 2024). Notably, reduced school belonging led to increased camouflaging within school \u0026ndash; the hiding and adapting of Autistic traits to fit in \u0026ndash; thereby increasing anxiety.\u003c/p\u003e\u003cp\u003eOvertime, the expectation of negative social outcomes \u0026ndash; including social relationship issues and difficulties - became a barrier to school anxiety (Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Costley et al. (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) found that social relationships provoked anxiety, due to fear of causing offense or conflict. This anticipatory social fear extended into specific school activities, with Reyes et al. (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reporting that entering new peer groups, participating in group projects, and delivering class presentations were common anxiety triggers.\u003c/p\u003e\u003cp\u003eA hostile social environment also heightened anxiety through fear of judgement. CYP worried about saying the wrong thing or being perceived negatively (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Notably, this was the only study to identify bullying as a contributor to school anxiety, with students often targeted for visibly deviating from neuro-normative standards - such as attending a support unit. Reyes et al. (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) further identified intersectional challenges among those who experienced racism.\u003c/p\u003e\u003cp\u003eFinally, a lack of social safety was also influenced by the unpredictable and disruptive behaviours of other students. Both Costley et al. (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Reyes et al. (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that rule-breaking and physical aggression from other CYP heightened school anxiety.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAcademic and Cognitive Demands\u003c/h2\u003e\u003cp\u003eAutistic students also faced academic and cognitive expectations - rooted in neuro-normative expectations of what, how, and when students are expected to learn and behave to be academically successful \u0026ndash; as contributors to school anxiety (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Clark and Adams., 2020). In Clark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), parents cited several barriers directly tied to these expectations. The most frequently reported barriers were task demands, expectations, and time pressures, followed by communication and learning difficulties, and fear of failure. Costley et al. (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) similarly found that academic pressures contributed to anxiety, from everyday classroom tasks \u0026ndash; such as answering a question \u0026ndash; to more intense stress during formal assessments or exams. Importantly, cognitive pressures extended beyond academic tasks and involved aspects of the \u0026lsquo;hidden curriculum\u0026rsquo;, including punctuality. These pressures were often exacerbated by difficulties concentrating in class.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePhysical and Structural Design\u003c/h2\u003e\u003cp\u003eFour studies identified the physical and structural design of school environments \u0026ndash; including spatial layouts, schedules, and environments that scaffold daily school life - as contributors (Clark and Adams., 2020; Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Sideropoulos et al., \u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Overwhelming sensory environments were prominent contributors across three qualitative studies (Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Clark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), 62.5% of parents selected \u0026ldquo;overstimulation, unpredictability and demands at school\u0026rdquo; as the primary barrier to managing school anxiety, with \u0026lsquo;noise, chaos, and overstimulation\u0026rsquo; commonly cited. Similarly, Costley et al (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Reyes et al (\u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported excessive noise in school as a key cause of school anxiety. Large crowded secondary school environments were particularly anxiety evoking, where sensory demands intensified (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). \u0026lsquo;Not enough downtime, breaks, or access to quiet spaces\u0026rsquo;, reported by Clark and Adams (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), compounded this anxiety by removing opportunities for sensory regulation.\u003c/p\u003e\u003cp\u003eBeyond sensory stressors, change, unpredictability, and transitions emerged as key causes of school anxiety (Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Students experienced anxiety in response to unexpected change in routine, unfamiliar social environments, and new teaching staff (Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The transition to secondary school was identified by two studies as a contributor. Costley et al (\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) identified that environmental and structural issues were worsened in secondary school \u0026ndash; including sensory overload and uncertainty about what the new environment would entail. However, Sideropoulos et al. (\u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), in a longitudinal study, found no significant change in anxiety scores across the transition.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur novel systematic review identified and synthesised contributing factors to school anxiety among Autistic CYP. Prioritising contributors is critical to avoid framing anxiety as inherent to Autism and to develop meaningful interventions (Chapman and Carel, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). For example, Adams et al (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), applying similar criteria but not focussing on contributors, found 12.5% of studies with a genetic and biologically essentialist focus (Roohi et al., \u003cspan citationid=\"CR243\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Gadow et al., 2008, 2009, \u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile \u0026lsquo;school anxiety\u0026rsquo; is widely explored (Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), only eight studies met our inclusion criteria \u0026ndash; indicating essentialist understandings still dominate (Botha, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2021b\u003c/span\u003e). This is striking given elevated anxiety rates and growing recognition of associated school-based contributors among Autistic CYP (Thiele-Swift and Dorstyn, \u003cspan citationid=\"CR273\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Clark and Adams, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In contrast, contributor reviews among Neurotypical populations with narrower search pools identified 26 studies on teacher-student relationships (Salter et al., \u003cspan citationid=\"CR251\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and 44 on academic achievement (Brumariu et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis gap itself reflects neuro-normative epistemic injustice \u0026ndash; a macrosystemic context shaping both micro-level and individual experiences (Legault et al., \u003cspan citationid=\"CR183\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Catala et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e). Yet this macrosystemic context was entirely absent from reviewed studies, revealing limited epistemic depth from a critical realist lens (Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e; Lawani, \u003cspan citationid=\"CR179\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Brofenbrenner, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). Critical realism posits a stratified ontology: the \u003cem\u003eempirical\u003c/em\u003e (observable experiences), the \u003cem\u003eactual\u003c/em\u003e (events that occur irrespective of observation), and the \u003cem\u003ereal\u003c/em\u003e (causal mechanisms) (Bhaskar, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). While individual- and micro-level studies offer useful empirical and actual insights, it is only through theorising the macrosystem \u0026ndash; situated within the real \u0026ndash; that we can understand how these surface patterns are generated and sustained (Wiltshire, \u003cspan citationid=\"CR288\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithout this, recommendations risk reinforcing essentialism and committing the epistemic fallacy \u0026ndash; conflating complex, stratified phenomena with only what is measurable (Stahmer et al., \u003cspan citationid=\"CR267\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Brunson et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Bhaskar, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Inconsistencies or non-significant individual-level findings may reflect misalignment between observed variables, like gender and age, and deeper causal mechanisms (Bhaskar, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e). Even significant findings lack explanatory meaning if confined to the empirical. For example, Syriopoulou-Delli et al. (\u003cspan citationid=\"CR271\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reported significant correlations between school anxiety, IQ, and speech ability, but \u0026lsquo;fluent speech\u0026rsquo; may simply increase detection of anxiety via neuro-normative measures (Perihan et al., \u003cspan citationid=\"CR219\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similarly, age effects may reflect comprehension bias (Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e), rather than genuine developmental change (Schiltz and Magnus, \u003cspan citationid=\"CR253\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In open and complex systems, isolating surface-level variables without interrogating their macrosystemic roots yields tentative and potentially misleading insight (Wiltshire, \u003cspan citationid=\"CR288\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFive studies explored micro-level contributors, framed here as neuro-normative affordances. These may underlie individual-level differences observed empirically (Bhaskar, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Archer, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e); for example, \u0026lsquo;older age\u0026rsquo; (Adams et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019b\u003c/span\u003e) may reflect distinct demands associated with secondary school (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Though these studies engaged Autistic CYP\u0026rsquo;s lived experiences, none included macrosystemic theorisation - limiting explanatory power.\u003c/p\u003e\u003cp\u003eOnly two studies explored academic and cognitive demands \u0026ndash; a concerning gap given elevated exam anxiety and fear of failure among Autistic CYP (Wood \u0026amp; Happ\u0026eacute;, \u003cspan citationid=\"CR290\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR259\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, the hidden curriculum\u0026mdash;unspoken behavioural norms students are assumed to intuit\u0026mdash;appeared in just one study, despite its disproportionate impact (Costley et al., \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Poed \u0026amp; Fox, \u003cspan citationid=\"CR227\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Moyse \u0026amp; Porter, \u003cspan citationid=\"CR205\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). None situated these demands within broader macrosystemic contexts such as rigid, neuro-normative academic standards or national curricula, limiting the feasibility of practice suggestions within system constraints (Williams-Brown and Jopling, \u003cspan citationid=\"CR284\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Future research must interrogate how academic macrosystems contribute to anxiety.\u003c/p\u003e\u003cp\u003eSocial affordances appeared in four studies, reflecting patterns of bullying, negative peer interactions and identities, and unsafety among Autistic learners (Williams et al., \u003cspan citationid=\"CR282\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Billington et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cohen et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Camouflaging \u0026ndash; adapting or suppressing Autistic traits to meet neuro-normative expectations (Mullally et al., 2024) \u0026ndash; was identified in just one study, despite its well-established association with unsafe environments and poor mental health (Atkinson et al., 2024; Howe et al., \u003cspan citationid=\"CR158\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Chapman et al., \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ai et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Moreover, only one study provided a theoretical lens, framing school belonging - feeling accepted, respected, and included \u0026ndash; as central to anxiety (Atkinson et al., 2024). Given emerging evidence that systemic rejection legitimises exclusion (Fisher et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e), the absence of macrosystemic analysis signals a pressing gap for future research.\u003c/p\u003e\u003cp\u003eFinally, four studies identified physical and structural affordances. School sensory environments are well-documented to cause distress \u0026ndash; through sensory overload and disrupted learning (Jones et al., \u003cspan citationid=\"CR164\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Howe and Stagg, \u003cspan citationid=\"CR156\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Acker et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) \u0026ndash; only three studies directly linked this to school anxiety. Unpredictability \u0026ndash; particularly around school transitions - also emerged as a key contributor, with its role in fuelling anxiety well-established in wider literature (Boulter et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Jenkinson et al., \u003cspan citationid=\"CR162\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Nuske et al., 2019; Yates et al., \u003cspan citationid=\"CR292\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCrucially, all studies examined affordances in isolation, detached from their macrosystemic context. This fragmented approach oversimplifies schools as static rather than dynamic, interdependent systems in which anxiety is co-produced by interacting mechanisms (Fielding et al., \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2025b\u003c/span\u003e). Without a macrosystemic lens, research risks reductionism - applying closed-system logic to a complex, open, system \u0026ndash; and overlooks systemic inertia (Williams-Brown and Jopling, \u003cspan citationid=\"CR284\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e; Bhaskhar, 1998). Such epistemological limitations may underlie findings like Sideropoulos et al. (\u003cspan citationid=\"CR257\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), who reported no change in anxiety during school transitions despite multiple interacting mechanisms. To generate meaningful recommendations for policy and practice, future research must move beyond surface correlates to interrogate the deeper macrosystemic drivers of school anxiety (Fisher et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2025a\u003c/span\u003e; Brunson et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of Existing Research\u003c/h2\u003e\u003cp\u003eThe limitations of reviewed studies reflect not only gaps in \u003cem\u003ewhat\u003c/em\u003e is examined, but \u003cem\u003ewhose\u003c/em\u003e knowledge is recognised and \u003cem\u003ehow\u003c/em\u003e it is generated. A key issue is testimonial injustice \u0026ndash; the systemic devaluation of Autistic perspectives due to presumed incredibility (Legault et al., \u003cspan citationid=\"CR187\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Fricker, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Non-Autistic informants outnumbered Autistic voices by approximately 2.5:1. Only two studies incorporated Autistic community input; three used deficit-based terminology. Yet, Autistic people are uniquely positioned to access the actual and real domains of their experience (Fletcher-Watson et al., \u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kourti, \u003cspan citationid=\"CR173\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Autism is embodied: while a meltdown may be empirically observable, only the Autistic person can understand its internal (actual) experience \u003cem\u003e(\u003c/em\u003eRosqvist et al., \u003cspan citationid=\"CR245\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Ethically grounded participatory research is essential to understand macrosystemic factors underlying school anxiety (Russell and Wilkinson, \u003cspan citationid=\"CR247\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, no study demonstrated reflexivity regarding the researcher-participant relationship, risking shallow interpretation and missed causal depth (Botha, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIntersecting epistemic injustices were also rarely acknowledged (Botha and Gillespie-Lynch, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Omodan, \u003cspan citationid=\"CR215\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). All studies recruited via services or schools, and only one allowed self-identification without diagnosis - excluding those most marginalised by school anxiety, including those off-roll, unable to attend, or in diagnostic limbo (Children\u0026rsquo;s Commissioner, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e; Adams, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Children\u0026rsquo;s Commissioner, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e). These CYP also face systemic barriers to support, with only one in four receiving support when sought (Doherty et al., \u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ashworth et al., 2025). Recruitment practices likely compounded participation disparities: male-to-female ratios approached 3:1, reflecting chronic under-identification of Autistic girls (Daniel and Wang, \u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Milner et al., \u003cspan citationid=\"CR201\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Ethnicity was rarely reported; where it was, White participants were overrepresented, reflecting racial disparities in diagnosis and service access (Lindsay et al., \u003cspan citationid=\"CR191\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lovelace et al., \u003cspan citationid=\"CR195\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Such oversights narrow the epistemic lens, risking partial understandings of school anxiety that neglect intersectional identity-based marginalisation (Reyes et al., \u003cspan citationid=\"CR237\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Cohen et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Future research must centre under-represented CYP through participatory and inclusive recruitment (Cascio et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese shortcomings are rarely within the remit of individual studies, nor are they captured by typical quality assessments. Only one study fell below the STROBE cut-off; the remainder were deemed moderate to high quality. This highlights a deeper hermeneutical injustice \u0026ndash; a lack of conceptual tools to recognise, evaluate, and interpret Autistic and intersectional experiences (Catala et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fricker, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This is evident in the near-exclusive focus on Autistic CYP without intellectual disabilities in mainstream education. Across the field, nearly 80% of studies disproportionately exclude Autistic CYP with intellectual disabilities due to inaccessible methodologies (Catala, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Mingins et al., \u003cspan citationid=\"CR203\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Russell et al., \u003cspan citationid=\"CR249\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Greater inclusion demands flexible, adaptive methods (Lewis et al., \u003cspan citationid=\"CR189\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) built through epistemic inclusion of Autistic CYP with intersecting marginalisations (Hofmann, \u003cspan citationid=\"CR152\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMeasurement was another site of injustice. Three studies used scales developed for Neurotypical populations (e.g., SCARED and SAS-TR; Lyneham et al., \u003cspan citationid=\"CR197\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Garcia-Fernandez et al., 2014; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), embedding neuro-normative assumptions about anxiety expressions (Perihan et al., \u003cspan citationid=\"CR219\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These measures risk pathologising Autistic traits, overlooking non-neuro-normative expressions, and conflating observable behaviour with presumed internal states - an epistemic fallacy (Brunson et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Rapaport et al., \u003cspan citationid=\"CR233\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Schiltz and Magnus, \u003cspan citationid=\"CR253\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stern et al., \u003cspan citationid=\"CR269\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For example, limited speech may be interpreted as social anxiety, despite alignment with Autistic traits within the Autism Quotient (Gupta et al., \u003cspan citationid=\"CR148\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lyneham et al., \u003cspan citationid=\"CR197\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Baron-Cohen et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). In contrast, scales developed for Autistic populations - like the ASC-ASD, used in two studies \u0026ndash; better capture anxiety among Autistic CYP (Goulding et al., \u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). As highlighted in prior reviews (Perihan et al., \u003cspan citationid=\"CR219\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ambrose et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e), future research must prioritise the development of measurement tools capable of disentangling Autistic traits from anxiety to evade pathologising narratives.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eLimitations of our review\u003c/h2\u003e\u003cp\u003e The internal validity of our review is open to critique. The small number of included studies, combined with high heterogeneity, limited the feasibility and coherence of advanced synthesis methods (Popay et al., 2006). Inter-rater reliability was also not feasible across all stages, increasing vulnerability to human error and subjectivity (Belur et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur review is not intended to be generalisable to broader research on negative school experiences among Autistic learners. To ensure conceptual precision and methodological rigour, eligibility criteria were restrictive, excluding studies without an explicit focus on anxiety (Dekkers et al., \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Terminological inconsistency further complicated this, with several studies examining conceptually overlapping but differently labelled phenomena \u0026ndash; including school experiences (Billington et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Goodall, \u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), identity (Cohen et al., \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), wellbeing (Danker et al., \u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), emotionally based school avoidance (Hamilton, \u003cspan citationid=\"CR150\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and inclusion (Lebenhagen, \u003cspan citationid=\"CR181\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Other Neurodivergent groups, such as ADHD (Mansfield \u0026amp; Soni, \u003cspan citationid=\"CR199\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and dyslexia (Novita, \u003cspan citationid=\"CR211\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), were also excluded despite frequent diagnostic and experiential co-occurrence (Astle et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe exclusion of growing literature using the term \u003cem\u003eschool distress\u003c/em\u003e also limits our scope. We excluded this body of work due to its relative novelty and less established conceptualisation (Connolly et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Adams et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019a\u003c/span\u003e). While conceptual distinctions remain underdeveloped, it is likely that distress both contributes to, and is shaped by, anxiety. Notably, contributors identified \u0026ndash; including poor support, unpredictability, unsafety, sensory distress, and bullying \u0026ndash; appear to precede both constructs (Fielding et al., \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Mullally and Connolly, \u003cspan citationid=\"CR209\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis presents a central limitation: by narrowing our scope, our review risks replicating the very criticisms levelled at the included studies \u0026ndash; fragmentation and limited theoretical depth. As such, while our findings offer a valuable foundation for understanding school anxiety, they must be interpreted with caution and an awareness of these exclusions.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur novel review highlights significant gaps in the evidence base on what contributes to school anxiety among Autistic CYP. Despite the term\u0026rsquo;s widespread use, only eight studies explicitly investigated contributing factors \u0026ndash; suggesting its popularity may be shaped by essentialist understandings and longstanding epistemic injustice. Crucially, no studies interrogated the deeper, macrosystemic conditions \u0026ndash; rooted in neuro-normative epistemic injustice, and embedded within culture, policies, and dominant knowledge systems \u0026ndash; that make school anxiety-evoking for Autistic CYP. These structural conditions produce the identified micro-level hostile social experiences, academic expectations, and structural conditions that may manifest as individual-level differences in school anxiety in IQ, age, and gender.\u003c/p\u003e\u003cp\u003eWithout theorising macrosystemic context, research offers only superficial insights, leaving effective, feasible interventions out of reach. Most concerningly, current approaches risking reinforcing the assumption that anxiety is inherent to Autism, rather than a product of systemic failure.\u003c/p\u003e\u003cp\u003eFuture research must urgently expand the field\u0026rsquo;s epistemic scope. This includes amplifying Autistic voices \u0026ndash; particularly those facing intersecting epistemic injustices \u0026ndash; and interrogating the macrosystemic context. It also requires moving beyond standardised tools rooted in neuro-normative assumptions, and towards, participatory, inclusive methodologies that centre lived experience. Only through such depth-oriented, epistemically just inquiry can we begin to develop meaningful, implementable interventions that reflect and respond to the lived realities of school anxiety among Autistic CYP.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests and Funding:\u0026nbsp;\u003c/strong\u003eNo funding was received to assist with the preparation of this manuscript. The authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e With sincere thanks to the Autistic individuals whose insights and experiences shaped and strengthened our conceptual understanding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eACARA. 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The psychological impact of the secondary school transition on families of autistic children. \u003cem\u003eInternational Journal of Developmental Disabilities\u003c/em\u003e, \u003cem\u003e70\u003c/em\u003e(7), 1207-1217. https://doi.org/10.1080/20473869.2023.2170004\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Newcastle University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"School Anxiety, Autism, Epistemic Injustice, Attendance, Neuro-Normativity, School Policy","lastPublishedDoi":"10.21203/rs.3.rs-7711229/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7711229/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAnxiety about school is becoming increasingly recognised among Autistic learners, yet the term is often applied in essentialist ways that obscure underlying contributors. Our systematic review aimed to identify and evaluate research examining psychosocial contributors to school anxiety among Autistic learners. We included studies which reported a relationship \u0026ndash; without attributing it to a non-contributing reason - between school anxiety and a psychosocial factor among Autistic learners. We searched PsycINFO, Medline, ERIC, and Scopus through March 2025.\u003c/p\u003e\u003cp\u003eEight papers (N\u0026thinsp;=\u0026thinsp;767 participants) met inclusion criteria, including three qualitative and five quantitative studies. We conducted a narrative synthesis and assessed quality using STROBE and CASP. Three studies investigated individual-level factors (e.g., age, gender) with mixed significance. Five identified micro-system level contributors: social expectations (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), academic and cognitive expectations (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2), and physical design (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;4).\u003c/p\u003e\u003cp\u003eUsing a critical realist lens, we propose a layered ecological framework in which neuro-normative epistemic injustice shapes the micro-system through school-based contributors, or affordances, that manifest as individual differences. Eligible studies were limited in epistemic depth, which overlooked interrelations and deeper macro-systemic mechanisms. Despite generally moderate to high quality, key limitations included reliance on service-based recruitment, underrepresentation of marginalised identities, and dominance of non-Autistic informants \u0026ndash; reinforcing epistemic injustice by sidelining Autistic perspectives.\u003c/p\u003e\u003cp\u003eOur findings highlight the need for inclusive, participatory methods capable of capturing the complex, macrosystemic realities of Autistic learner\u0026rsquo;s experiences of school anxiety.\u003c/p\u003e","manuscriptTitle":"School Anxiety Experienced by Autistic Children: A Systematic Review of Contributing Factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 10:48:59","doi":"10.21203/rs.3.rs-7711229/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8748532-8dfa-48ba-8adb-c82f0689333d","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55320358,"name":"Psychology"}],"tags":[],"updatedAt":"2025-09-26T10:48:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-26 10:48:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7711229","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7711229","identity":"rs-7711229","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}