Trajectories of school refusal: sequence analysis using retrospective parent reports

Trajectories of school refusal: sequence analysis using retrospective parent reports | 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 Research Article Trajectories of school refusal: sequence analysis using retrospective parent reports Laelia BENOIT, Edith CHAN SOCK PENG, Julien FLOURIOT, Madeline DIGIOVANNI, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3453432/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2024 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted 8 You are reading this latest preprint version Abstract Background School refusal (SR) is a form of school attendance problem (SAP) that requires specific mental health care. Despite improvements in the definition of SAPs, the course of SR is not well characterized. Methods To explore three-year patterns of SR course in children, as reported by their parents, we deployed an anonymous web-based survey. We defined SR onset as the absence of ≥ 2 school weeks during one academic year, combined with emotional distress. We defined standard SR trajectories using sequence analysis of parents’ recollection of three consecutive years of school attendance. Results We obtained 1,970 responses, 1,328 (67%) completed by a parent and meeting the definition of SR. Of these, 729 (55%) responses included three years of school attendance recollection. We identified five prototypical trajectories of SR: two profiles for children: beaded absences (n = 272), and rapid recovery (n = 132); and three for adolescents: prolonged recovery (n = 93), gradual decline (n = 89), and rapid decline (n = 143). Conclusion We found five distinct trajectories of retrospective recall of SR course. Through pattern recognition, this typology could help with timely identification of SR and implementation of evidence-based interventions to optimize outcomes. Prospective replication of these findings and their field application is warranted. school refusal outcome course sequence analysis school attendance problems trajectories Figures Figure 1 INTRODUCTION School attendance problems (SAPs) are associated with increased risk of early and permanent school dropout and of developing psychiatric disorders [ 1 – 3 ]. In the longer term, SAPs are linked to economic and social precariousness [ 1 , 4 , 5 ]. Mounting concern about such consequences has led researchers to better define SAPs in an effort to provide early interventions for affected children [ 1 , 6 – 8 ]. Most authors use Kearney’s criteria for problematic absenteeism to identify children with SAPs, namely: (1) missing at least 25 percent of total school time for at least two weeks; (2) experiencing severe difficulty attending classes for at least two weeks with significant interference in a child’s or family’s daily routines; and/or (3) being absent for at least 10 days of school during any 15-week period while school is in session [ 9 ]. Heyne et al. [ 10 ] differentiated four distinct categories of SAPs: (1) school refusal (SR, compounded by emotional distress); (2) truancy (when the child conceals absenteeism from their parents); (3) school withdrawal (through parental neglect); and (4) school exclusion (through a school decision). In their detailed definition, SR occurs when a young person: (1) is reluctant or refuses to attend school, in conjunction with emotional distress that is usually made manifest by absences, although not necessarily so, as in the case of repeat late arrivals; (2) does not try to hide absences from their parents; (3) does not display antisocial behavior beyond resistance to parental attempts to get them to school; and (4) parents have made reasonable efforts to secure attendance at school [ 10 ]. In non-clinical population, school fear is associated with internalizing problems [ 7 ]. The prevalence of SR ranges between 1 and 5%, with no difference across genders [ 11 , 12 ]. In the DSM-5, SR is often co-occurring, a clinical presentation sometimes associated with social or specific phobias, or with generalized anxiety, major depressive, oppositional defiant, post-traumatic stress, or adjustment disorders, among others [ 13 ]. Three developmental stages have been identified as conducive to SR: between 5 and 6, 10 and 11, [ 14 ] or 13 and 15 years of age [ 15 , 16 ]. Prolonged absence can compromise learning, socialization, and self-esteem, and thus affect later academic and developmental milestones [ 5 , 12 ]. Social phobia and learning difficulties have been found to predict poorer functional outcomes [ 17 ]. Based on a national health survey in France, we conducted a retrospective study based on parental responses. We sought to identify distinctive course and outcome in SR over the first three years of onset. METHODS Design In partnership with the educational policy department of the French Ministry of Education (DGESCO) and with parent representatives from the School Refusal Association (APS), we developed a web-based survey using Lime Survey software [ 18 ]. APS is a parent-led support group that aims to develop better understanding, recognition, and care of SR. The study was approved by the Ethics Evaluation Committee of the National Institute of Health and Medical Research (Inserm, IRB #00003888). Instruments The survey was intended for parents who believe their child suffers or has suffered SR, whether formally diagnosed or not (see survey content in Appendix 1 ). The survey defined SR upfront: “School refusal is reluctance or refusal to attend school, associated with emotional distress”. The survey asked 36 questions about the index case: 1) socio-demographic characteristics; 2) SR trajectory (age of onset, course); 3) SR clinical characteristics (symptoms, associated diagnoses) 4) clinical care and 5) school flexibility. We did not collect any personally identifying information. SR course after onset was assessed from retrospective recollection of school attendance and emotional distress from ages 5 to 20 years old. Question #15 began with the stem "This year my child was:" and provided eight forced-answer choices: "Present all year and comfortable at school," "Present all year but felt poorly at school,” "Absent for less than two weeks," "Absent between two and four weeks," "Absent more than a month but less than one trimester," "Absent one trimester," "Absent two trimesters," or "Absent throughout the school year." Our inclusion criterion was ≥ 2 school week absences for at least one year [ 10 ]. We defined SR onset as the child’s age at the time of their first school absence lasting at least two weeks. Data collection Between May and October 2018, a link to the anonymous survey was deployed by: 1) DGESCO, through the superintendents of six major educational regions; and 2) APS, through its private Facebook page, followed by 4,542 individuals by the end of the data collection interval. The investigators did not have access to email addresses, the private Facebook group, or any personally identifying data. Statistical analysis We compared continuous and categorical variables using ANOVA and Fisher’s Exact Test, respectively. We calculated two-sided p-values with a significance threshold of < 0.05. To refine comparisons between clusters for variables on which the Fisher Exact Test showed that at least one cluster is significantly different from the others (p < 0.05), we tried all possible groupings of clusters in two macro-groups and looked for statistically significant differences (see Appendix 2 ). Given the exploratory nature of this study, we did not correct for multiple comparisons. We analyzed descriptive variables using R (Version 3.6.0) [ 19 ]. To determine school refusal trajectories, we used sequence analysis, which aims to identify similar series of successive states ("standard sequences") within a corpus of sequences [ 20 ]. Sequence analysis is a non-parametric cluster analysis technique, also called unsupervised clustering technique. Unsupervised clustering is exploratory by nature as the induction of data is automated and based on disaggregated data. As such, variables are not selected: all variables are tested in this large-scale exploratory statistical method. Unsupervised clustering is increasingly used in medicine, including in mental health research, to decompose the heterogeneity of clinical presentations [ 21 , 22 ]. It can be used safely on a large sample, as it is the case in this study. We formed clusters using sequence analysis on the variable "This year my child was" for the 3 years after the beginning of SR (including the year of onset), for the subsample of children for whom school attendance data were available for a minimum of three years after SR onset. Each trajectory was considered a unique sequence within a finite number of possibilities, i.e. the eight forced-choice responses. We calculated sequence similarity using the optimal matching algorithm of the TraMineR package (version 2.0-11.1) [ 20 ]. We calculated a substitution matrix by converting the eight absenteeism modalities to their equivalent in days and then calculating the difference in days when moving from one state to another. We used the Hubert C index (HC) from the R Weighted Cluster library (version 1.4) to assess the quality of the clusters we obtained. HC compares the partition obtained to the theoretically best partition possible for a given number of groups. The closer the HC is to 0, the more adequate the clusters [ 23 ]. We then described the resulting clusters using variables from the following categories: 1) socio-demographics; 2) SR characteristics; 3) clinical care; and 4) school flexibility. RESULTS Sample The survey link was opened on 2,511 instances, yielding 1,970 complete responses, 1,413 (73%) of them meeting the definition of SR. We excluded 85 (6%) responses completed by adult subjects who had suffered from SR in their childhood. The analysis included 1,328 parental responses, with 1,274 (96%) by mothers. We assessed the relevance of our definition of SR: among the 1328 responses included, 99% children displayed at least one criterion that distinguishes SR from other SAPs (i.e., anxiety, panic attacks). Genders were equally distributed (49% female). At the time of questionnaire completion, mean subject age was 14.7 ± 3.2 years, 887 subjects (67%) had partnered or married parents, and 907 (69%) lived with both parents at the time of SAP onset. Parents’ education level was higher than the national average: 679 (51%) had a diploma equivalent or more than 2 years of post-graduate study, compared to 22% in the general French population, ages 25 to 64 [ 24 ]. Most families (n = 1231, 93%) only spoke French at home. Mean age of SR onset was 13 ± 4 years. During the two years preceding onset, 323 children (24%) had experienced serious illness or the death of a loved one, 311 (23%) a change of school, 213 (16%) a move, and 157 (12%) a change in family organization. Additionally, 823 (62%) experienced some form of pressure from school, their parents, and/or themselves, 634 (48%) been victims of bullying, insults, or threats, and 206 (16%) of physical violence. Prodromal presentations such as oppositional, depressive, anxious, or somatic symptoms were first evident upon or in anticipation of attending school, at a mean age of 8 ± 4 years. Risky screen use was reported by 691 participants (52%). SR was associated with at least one other diagnosis among 1,167 children (88%). The most frequent conditions were depression (n = 425, 33%) and social phobia (n = 367, 28%). See Table 1 for further details. Table 1 School refusal characteristics in the survey sample (n = 1,328) N = 1,328 Yes SR definition: > 2 weeks of school absenteeism with emotional distress 1,328 (100) ≥ 1 distinctive criterion of SR: diagnosis of SR by a health care provider; panic attacks; anxiety; stomachaches; headaches; sleep problems 1,309 (99) School refusal characteristics Diagnosis of SR by a health care provider 930 (70) Manifestations related to school attendance Panic attacks 1,125 (85) Sleep problems 912 (68) Stomachaches 1079 (81) Headaches 811 (61) Anxiety 837 (63) Anger 338 (26) Parents’ perception of risky use of screens (smartphone, video games, social networks) 691 (52) Performance anxiety 671 (51) Separation anxiety 503 (38) Complaints toward: School 459 (35) Classmates 338 (26) Teachers 302 (23) Drop in academic performance 399 (30) Arguments with authority figures 388 (29) ≥ 1 associated condition diagnosed by a care provider 1,167 (88) Depression 425 (33) Social Phobia 367 (28) Learning disability (e.g., dyslexia, dyspraxia, dysgraphia, dyscalculia) 269 (20) Attention-Deficit/Hyperactivity Disorder (ADHD) 142 (11) Post-Traumatic Stress Disorder 100 (8) Aggravation of preexisting medical conditions (e.g., asthma, diabetes) 87 (7) Eating disorder (i.e., anorexia, bulimia) 85 (7) Generalized Anxiety Disorder 71 (5) Autism Spectrum Disorder 67 (5) Bipolar disorder 12 (1) Obsessive Compulsive Disorder 17 (1) Schizophrenia 6 (0.5) Relationship with professionals Sense of understanding: kindness and availability of at least some interlocutors School 908 (68) Healthcare providers 1040 (78) Sense of rejection: criticism, threat, judgments School 354 (27) Healthcare providers 103 (8) Values represent n (%), unless noted otherwise. INSERT Table 1 ABOUT HERE Regarding school adaptations, 759 children (61%) had adjusted school schedules (such as reduced timetables or personal support plans), and 354 parents (27%) felt rejected or criticized by school professionals. Half of the children (n = 681, 54%) received at least one pharmacological treatment, and for 546 (44%), the first health professional consulted was their family doctor. Half of the families spent more than 150 euros/month in non-reimbursed care (min ≤ med ≤ max: 0 ≤ 150 ≤ 3000), and 912 (69%) parents adjusted their work schedules to adapt to their child's SR. Trajectories of school refusal during the first three years after onset Retrospective recall of school attendance during the first three years after SR onset was provided for 729 (55%) subjects. Individual trajectories of SR during this time are represented in Supplementary Fig. 1 using dendrograms , tree diagrams depicting taxonomic relationships. Absences of less than two weeks or between two weeks and one month were observed among 211 (29%) and 175 (24%) children during the second and third year after SR onset, respectively. Complete return to school and return to school with discomfort were observed among 124 (17%) and 146 (20%) children during the second and third years, respectively. We set the optimal number of clusters at five, following the optimal matching algorithm ( Supplementary Fig. 2 ). An HC of 0.1 confirmed the robustness of fit for these five clusters. Children’s individual trajectories of SR according to each cluster are depicted in Fig. 1 . INSERT FIGURE 1 ABOUT HERE Characteristics of five SR trajectory clusters Table 2 shows socio-demographic characteristics, SR characteristics, associated diagnoses, characteristics of care and school flexibility across the five clusters. Age of onset was lower in Clusters 1 and 2, “children,” than in clusters 3, 4, and 5 “adolescents” (p < 0.001). Table 2 Sample characteristics, clinical care, and school flexibility across five school refusal trajectories (n = 729) Cluster Description (n) 1 Beaded absences (272) 2 Rapid recovery (132) 3 Prolonged recovery (93) 4 Gradual decline (89) 5 Rapid decline (143) Total sample (729) Cluster Comparisons p-value Significance Odd Ratio Sociodemographic characteristics Sex: male 140 (52) 73 (55) 40 (43) 43 (48) 72 (50) 368 (50) - - - - School refusal characteristics Age at onset (> 2 weeks of absence): mean years (SD) 9 (3) 10 (3) 12 (3) 11 (3) 12 (2) 11 (3) {3,4,5} > {1,2} {3,5} {3,5} {3,5} {1,2,3,5} 0.001 *** 2.2 Opposition: Refusal to attend appointments or hostility toward authority figures 130 (48) 54 (41) 30 (32) 52 (58) 68 (48) 529 (46) {1,2,4,5} > {3} 0.003 ** 1.92 {4} > {1,2,3,5} 0.008 ** 1.78 Headaches 189 (70) 76 (58) 52 (56) 54 (61) 82 (57) 453 (62) {1} > {2,3,4,5} 0.001 *** 1.66 Stomachaches 248 (91) 102 (77) 75 (80) 74 (83) 115 (80) 614 (84) {1} > {2,3,4,5} {1,4} 0.004 ** 4.32 Associated diagnoses Aggravation of preexisting medical conditions (e.g., asthma, diabetes) 22 (8) 23 (17) 7 (8) 7 (7) 5 (4) 64 (9) {1,2,3,4} > {5} 0.006 ** 3.09 {2} > {1,3,4,5} {4,5} 0.002 ** 1.81 {1,2} > {3,4,5} 0.001 *** 1.78 Social phobia 69 (25) 37 (28) 35 (38) 32 (36) 63 (44) 236 (32) {5} > {1,2,3,4} 0.001 *** 1.88 {3,4,5} > {1,2} {1,2,4,5} 0.001 ** 2.54 {3,5} > {1,2,4} {1,2} < 0.001 *** 2.16 Renounced some care for financial or organizational reasons (ns) 159 (58) 72 (55) 41 (44) 46 (51) 76 (53) 394 (54) - - - - Frequency of care appointments: at least once a week * 70 (26) 41 (31) 33 (35) 18 (20) 44 (31) 206 (28) ns ns ns ns Psychotherapy (> 1 type): individual; family; group therapy 62 (23) 40 (30) 27 (30) 28 (31) 63 (44) 220 (30) {5} > {1,2,3,4} {1,2,3,4} 0.001 *** 1.95 Psychotropic medication Antidepressant 84 (31) 39 (30) 49 (53) 42 (47) 63 (44) 277 (38) {3,4,5} > {1,2} {1,2,3,4} 0.002 ** 3.0 Perceived as efficient 45 (17) 19 (14) 24 (26) 12 (14) 14 (10) 114 (16) {3} > {1,2,4,5} 0.005 ** 2.11 > 1 type: antidepressant; anxiolytic; sleeping pill; ADHD medication; antipsychotic; herbal anxiolytic 71 (26) 26 (20) 36 (39) 35 (39) 47 (32) 215 (29) {1,3,4,5} > {2} 0.004 ** 1.89 {3,4,5} > {1,2} {1,2,3} 0.001 *** 2.1 Separation of children from parents suggested 52 (19) 22 (17) 27 (29) 25 (28) 55 (38) 181 (25) {5} > {1,2,3,4} {1,2} {1} 0.001 *** 1.67 {2,3,4} > {1,5} 0.001 *** 1.66 Change of school 106 (39) 62 (47) 54 (58) 45 (51) 74 (52) 341 (47) {2,3,4,5} > {1} 0.001 *** 1.66 Home schooling 42 (15) 28 (21) 19 (20) 32 (36) 55 (38) 176 (24) {4,5} > {1,2,3} {1,2,3,4} {2} 0.003 ** 1.72 Relationship with school: Sense of rejection 74 (28) 54 (41) 28 (30) 27 (30) 43 (30) 254 (31) {2} > {1,3,4,5} 0.005 ** 1.71 Values represent n (%), unless noted otherwise. * p < 0.05, ** p < 0.01, *** p ≤ 0.001. For cluster comparisons, we reported only results with the lowest p-value and sorted them out from the highest odd-ratio to the lowest. INSERT Table 2 ABOUT HERE Clusters 1 and 2: Young children The average age of onset for children in clusters 1 and 2 was respectively 9 ± 3 years and 10 ± 3 years, the youngest clusters in this study (p < 0.001). These children were more likely to have a diagnosis of learning disabilities (OR = 1.78, p < 0.001) than participants in clusters 3, 4 and 5. They were less likely to receive follow-up by a psychiatrist or a child psychiatrist (p < 0.001), antidepressants (p < 0.001) and multiple psychotropic medications (p < 0.001), than children in clusters 3, 4 and 5. Cluster 1: Beaded absences This cluster, the largest (n = 272, representing 37% of all respondents), describes a moderate, stable course over the first three years, with young children presenting with only short-term absences. Almost all children in cluster 1 (n = 267, 98%) had at least one somatic symptom. They were more likely to experience stomachaches (n = 289; 91%, p < 0.001, OR = 2.57) and headaches (n = 189; 70%, p = 0.001, OR = 1.66) than the four other clusters. The latter were more likely to benefit from school accommodations (OR = 1.67, p = 0.001) or a change of school (OR = 1.66, p = 0.001), than children in cluster 1. Cluster 2: Rapid recovery This profile encompasses a high proportion of children with existing medical problems who tended to return to school by the second year of follow-up. In this cluster (n = 132), SR was associated with a worsening of preexisting medical conditions more frequently (17%) than in the four other clusters (n = 23, p < 0.001). The three most common preexisting medical conditions were asthma, rare and/or chronic diseases, and digestive problems. Compared to the four other clusters, parents in cluster 2 reported more frequently not having met the education officer (OR = 1.72, p = 0.003) and feeling rejected by the school (n = 54, 41%, OR = 1.71, p = 0.005). If considered together with cluster 4, participants in cluster 1 and 2 reported higher levels of complaints toward school (OR = 1.83, p < 0.001), teachers (OR = 2.48; p < 0.001), and classmates (OR = 2.56; p < 0.001) than participants in clusters 3 and 5. Cluster 3, 4, and 5: Adolescents In clusters 3, 4 and 5, encompassing older children, participants were more likely to receive psychiatric follow-up (OR = 2.16, p < 0.001), a diagnosis of social phobia (OR = 1.87, p < 0.001), antidepressant medication (OR = 2.06, p < 0.001) or multiple medication (OR = 1.8, p < 0.001) than children in clusters 1 and 2. A separation of children from parents was more likely to be suggested for these three clusters (OR = 2.19, p < 0.001) than for participants in clusters 1 and 2. Cluster 3: Prolonged recovery For this cluster, SR onset was on average at age 12 ± 3. Children in the four other clusters were more likely to display oppositional behavior than the ones in cluster 3 (OR = 1.92, p = 0.003). Contrary to clusters 4 and 1, children in clusters 2, 3 and 5 were more likely to question their gender identity, although still infrequently (OR = 4.32, p = 0.004). Participants in cluster 3 obtained a formal SR diagnosis more often than other clusters (87%, n = 81, OR = 2.54; p = 0.001) and were more likely to perceive medication as helpful (n = 24, 26%, OR = 2.11, p = 0.005). These children may have benefited from an intensive healthcare response: 35% of them had at least one care appointment per week (n = 33, p = 0.02, cluster comparison = ns) and they were less likely to forego care for financial or organizational reasons (n = 41, 44%, ns). Cluster 4: Gradual decline SR started on average at 11 ± 3 years for the children in this cluster (n = 89, representing 12% of respondents). They maintained partial school attendance during the first two years, followed by cessation during the third. In comparison to the four other clusters, children in this cluster were more frequently angry about going to school (n = 36, 40%, OR = 2.2, p = 0.001), and more likely to express oppositional behavior (n = 52, 58%, OR = 1.78, p = 0.008). As mentioned above, participants in clusters 1, 2 and 4 complained more frequently about their school, teachers, and classmates than children in clusters 3 and 5. Cluster 5: Rapid decline In this profile, with an age of onset at 12 ± 2 years, school absenteeism persisted despite accommodations and medical monitoring. This cluster was the most likely to report social phobia, 44% (n = 63, OR = 1.88, p = 0.001). Children in this group had an intensive healthcare response. Compared to the four other clusters, participants in this cluster were more likely to receive more than one type of psychotherapy (44%, n = 63, OR = 2.15, p < 0.001), to having been hospitalized in a psychiatry or pediatric unit (38%, n = 54, OR = 1.95, p = 0.001), and to receive antipsychotic prescriptions (10%, n = 15, OR = 3, p = 0.002). This cluster featured the highest frequency of homeschooling, for 38% of participants (n = 55, OR = 2.4, p < 0.001). Among these adolescents, a separation from parents was more likely to be suggested than in the four other clusters (OR = 2.28, p < 0.001). If considered together, participants in clusters 4 and 5 were more likely to feature homeschooling (OR = 2.75, p < 0.001) and to be subject to judicial or social services report (OR = 2.1, p = 0.001) than children in clusters 1, 2 or 3. DISCUSSION Latent profiles By acknowledging the varied factors associated with each subtype of SR, this common clinical presentation can be divided into more comprehensible, discrete patterns for parents, educators, and healthcare providers to identify. Through pattern recognition, such a typology could help with timely identification of SR and implementation of evidence-based interventions to optimize SR outcomes. Across all profiles, parents reported how their children’s attendance problems were frequently associated with related conditions, ranging from bullying, depression, social phobia, or gender identity issues. Somatic complaints were also common across profiles, in keeping with existing literature [ 25 – 27 ]. The high frequency of these concurrent concerns is arguably unique to SR within the broader domain of SAPs, as the definition of SR encompasses the child’s emotional distress [ 10 ]. SR may appear less stigmatizing than other SAPs and thus have an element of desirability for parents attempting to make sense of a difficult situation.. Nevertheless, the “long recovery” profile reports rapid medical and school support, echoing existing evidence suggesting that early and intensive care is associated with more favorable outcomes [ 28 ]. Parental involvement and school flexibility We found that a high degree of parental involvement may be associated with a better outcome, but only for certain interventions. Adaptation of parental work schedule was frequently reported across profiles. Alternatively, home-schooling was significantly higher for the two groups with more negative outcomes (“progressive worsening” and “rapid worsening”). Homeschooling may be a consequence of a prolonged absence, but this association may also be confounded by age: the average age of favorable profiles was lower than of unfavorable profiles, suggesting that the benefit may be a function of earlier intervention. Also, home schooling requires self-discipline and may therefore not be offered to younger children. To support parents’ efforts, schools serve as a second pillar in supporting favorable outcomes. School accommodations were least frequently reported for younger children, in the “beaded absences” and “rapid recovery” profiles. The “rapid recovery” profile was more likely to be associated with a physical illness or learning disability rather than psychiatric illness, suggesting that the intensity of school intervention may not be as significant for these children as for other profiles, instead favoring treatment of the underlying medical or learning condition [ 29 ]. In response to the high frequency of visits to the school nurse, as reported in this study, school-based attendance teams have been recommended to improve detection of risk factors for SR by monitoring students’ emotional distress, somatic symptoms, and parental motivations for absence [ 30 ]. The role of healthcare providers Healthcare providers are a third key stakeholder for children dealing with SR, and can provide additional screening, treatment, and advocacy for the conditions that contribute to SR. Nearly half of our sample had their first point of contact for SR with their family physician, and the overwhelming majority reported at least one associated diagnosis. Healthcare providers can support parents and schools by tailoring their approach according to SR subtype. For younger patients, SR may be more likely related to physical illness, so diagnosis of a physical illness at a doctor’s visit can include conversations with parents and schools about how to minimize distress and disruptions to school attendance. For older patients, healthcare providers can act as advocates between the school and mental health systems to address bullying, incorporate flexible school schedules, and recommend intensive mental health care. Regarding specific profiles, psychiatric medication use was more common for the older three profiles than for the younger two, as was follow-up with a psychiatrist, further suggesting a distinction between the younger child/medical or learning comorbidity-associated profiles, and the older child/psychiatric comorbidity-associated profiles. The “long recovery” profile, with high rates of diagnosis by a care provider, frequent appointments, and high satisfaction regarding medication, was associated with an eventual successful return to school after intensive support. Interestingly, psychiatric hospitalization was more frequent for the older profiles, but was not associated with any clear benefit for resolving SR. Qualitative research of psychiatric healthcare for adolescents struggling with SR suggests that adolescents find mental healthcare valuable in assisting with self-transformation and problem-solving abilities [ 31 ]. Additionally, a meta-analysis of the existing treatments for SR demonstrates that most interventions focus on cognitive behavioral therapy [ 32 ]. Together, these findings may explain the limited association of hospitalization and return to school demonstrated in this study: Acute hospitalizations may be more likely to focus on crisis stabilization rather than on the longer-term psychological coping that appears to be most valued and effective by adolescents. An additional point of intervention for healthcare workers is to monitor screen time: Risky screen use was reported by most participants across clusters. Increased screen time questions family functioning as a trigger or maintenance factor in SR [ 33 ], and therefore screen time monitoring should arguably include an assessment of the family’s ability to be engaged in the child’s trajectory. On the other hand, given that nearly a third of participants reported a feeling of rejection or criticism by the schools as relevant to their child’s trajectory, it is paramount that healthcare providers first build rapport with families to support them in being engaged with their child’s school trajectory, to avoid coming across as judgmental or intrusive. Parents of school-refusing children have already been shown to perceive a lack of understanding from schools in addressing their children, and the same dynamic should be avoided in healthcare [ 34 ]. Potential interventions may also focus on parental self-efficacy, a concept shown to be implicated in SR, although not quite predictive once controlling for child or parent comorbidities [ 35 ]. Underrepresented minorities with SR The vast majority of children in this study only spoke French at home, illustrating a known difficulty in accurately characterizing the SAP of children of underrepresented families (immigrants, ethnic minorities) [ 36 ] due to both a lack of representation in parental support groups and a mischaracterization of students’ and parents’ behaviors [ 37 , 38 ]. Indeed, the definition of parental “reasonable efforts” has been criticized for being left to the interpretation of professionals [ 38 , 39 ]. Nevertheless, parents from underrepresented groups may experience difficulties in communicating their concerns to school personnel [ 37 ], which may lead SR to be categorized as truancy or school withdrawal instead [ 38 ]. Similarly, young people from underrepresented groups experiencing emotional distress can feel ashamed to ask for help [ 40 ], leading to the conflation of truancy and SR. Limitations We acknowledge several limitations, the main one being the retrospective nature of this study. This study describes associations only, and therefore we cannot make any causative claims about what features of a trajectory are protective or harmful for a given child profile, limiting the strength of recommendations for future practice. Of note, we did not make corrections for the number of tests performed given the exploratory nature of this study. This study uses an unsupervised clustering technique, which requires a large sample. Therefore, further confirmatory studies should include a large sample. Alternatively, previous studies about school absenteeism [ 39 , 41 ] based on smaller samples used instead an inductive cluster analysis technique, in which different time patterns are first identified, then used as one variable. Participants were invited based on self-identification, not by formal delineation of SR versus other SAP, so it is unclear whether children described in this sample truly suffer from SR, as opposed to truancy, school withdrawal, or school exclusion. To more reliably characterize the subtypes of attendance problems, screening instruments are being developed and once validated may guide future studies [ 10 , 42 ]. Also, we noted a high frequency of parental involvement in our sample: Parents who are more involved may be more likely to participate in such a study. It is important to note that parental flexibility is a resource that not all children have access to; in our sample most children lived with both parents, who had higher employment and education metrics than average, such that this study does not adequately characterize the population of children without these presumably protective factors. This study may not accurately characterize the SAP of children of minority families due to their underrepresentation in the survey sample. Finally, future studies could explore the SR profiles based not only on parental reporting but on child self-reporting. Conclusion This study on subtypes of SR trajectories based on parental perspectives emphasizes seeking support for the distress central to SR. We hope our findings can help inform tailored supports for each profile of SR from three key stakeholders: parents, schools, and healthcare workers. A sense of trust and non-judgment between families, schools, and other providers is key toward creating an environment for children to remain engaged in their education and to cope with stressors in an adaptive way. Declarations Acknowledgments The authors are grateful to the crowd-funding platform Thellie, to private donors, and to the Jasmin Roy Foundation for their financial support. The Federation of the CMPP (Centre Médico Psycho Pédagogiques) and the Association Phobie Scolaire were helpful partners by sharing the link to the survey. Conflicts of interest The authors have no conflicts of interest to declare. Ethics approval This research was approved by the Ethics Review Committee of the French National Institute of Health and Medical Research (Inserm, IRB #00003888). References Kearney CA. School absenteeism and school refusal behavior in youth: A contemporary review. Clin Psychol Rev 2008;28:451–71. https://doi.org/10.1016/j.cpr.2007.07.012. Tramontina S, Martins S, Michalowski MB, Ketzer CR, Eizirik M, Biederman J, et al. School Dropout and Conduct Disorder in Brazilian Elementary School Students. Can J Psychiatry 2001;46:941–7. Kogan SM, Luo Z, Murry VM, Brody GH. Risk and Protective Factors for Substance Use Among African American High School Dropouts. Psychol Addict Behav 2005;19:382–91. McCune N, Hynes J. Ten year follow-up of children with school refusal. Ir J Psychol Med 2005;22:56–8. https://doi.org/10.1017/S0790966700008946. Flakierska N, Lindström M, Gillberg C. School Refusal: a 15–20-year Follow-up Study of 35 Swedish Urban Children. Br J Psychiatry 1988;152:834–7. https://doi.org/10.1192/bjp.152.6.834. King NJ, Bernstein GA. School refusal in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2001;40:197–205. https://doi.org/10.1097/00004583-200102000-00014. Steinhausen H-C, Müller N, Metzke CW. Frequency, stability and differentiation of self-reported school fear and truancy in a community sample. Child Adolesc Psychiatry Ment Health 2008;2:17. https://doi.org/10.1186/1753-2000-2-17. Kearney CA, Benoit L, Gonzálvez C, Keppens G. School attendance and school absenteeism: A primer for the past, present, and theory of change for the future. Front Educ 2022;7. Kearney CA. An Interdisciplinary Model of School Absenteeism in Youth to Inform Professional Practice and Public Policy. Educ Psychol Rev 2008;20:257–82. Heyne D, Gren-Landell M, Melvin G, Gentle-Genitty C. Differentiation Between School Attendance Problems: Why and How? Cogn Behav Pract 2019;26:8–34. https://doi.org/10.1016/j.cbpra.2018.03.006. Barrett PM, Ollendick TH. Handbook of Interventions that Work with Children and Adolescents: Prevention and Treatment. John Wiley & Sons; 2004. Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am 2005;14:773–95, ix. https://doi.org/10.1016/j.chc.2005.05.005. American Psychiatric Association. (2013). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm05. n.d. Ollendick TH, Mayer JA. School Phobia. In: Turner SM, editor. Behav. Theor. Treat. Anxiety, Boston, MA: Springer US; 1984, p. 367–411. https://doi.org/10.1007/978-1-4684-4694-4_9. Last CG, Strauss CC. School refusal in anxiety-disordered children and adolescents. J Am Acad Child Adolesc Psychiatry 1990;29:31–5. https://doi.org/10.1097/00004583-199001000-00006. Hersov L. School refusal. Br Med J 1972;3:102–4. https://doi.org/10.1136/bmj.3.5818.102. Mcshane G, Walter G, Rey JM. Functional Outcome of Adolescents with ‘School Refusal.’ Clin Child Psychol Psychiatry 2004;9:53–60. https://doi.org/10.1177/1359104504039172. LimeSurvey: An Open Source survey tool n.d. R Core Team (2020). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/. n.d. Gabadinho A, Ritschard G, Mueller NS, Studer M. Analyzing and Visualizing State Sequences in R with TraMineR. J Stat Softw 2011;40:1–37. Lombardo MV, Lai M-C, Baron-Cohen S. Big data approaches to decomposing heterogeneity across the autism spectrum. Mol Psychiatry 2019;24:1435–50. https://doi.org/10.1038/s41380-018-0321-0. Amoretti S, Verdolini N, Mezquida G, Rabelo-da-Ponte FD, Cuesta MJ, Pina-Camacho L, et al. Identifying clinical clusters with distinct trajectories in first-episode psychosis through an unsupervised machine learning technique. Eur Neuropsychopharmacol 2021;47:112–29. https://doi.org/10.1016/j.euroneuro.2021.01.095. Studer M. WeightedCluster library manual: A practical guide to creating typologies of trajectories in the social sciences with R 2013. Insee (National Institute of Statistics and Economic Studies). Niveau d’éducation de la population − France n.d. https://www.insee.fr/fr/statistiques/4238409?sommaire=4238781#consulter (accessed July 13, 2022). Li A, Guessoum SB, Ibrahim N, Lefèvre H, Moro MR, Benoit L. A Systematic Review of Somatic Symptoms in School Refusal. Psychosom Med 2021;83:715–23. Li A, Yang DD, Beauquesne A, Moro MR, Falissard B, Benoit L. Somatic symptoms in school refusal: a qualitative study among children, adolescents, and their parents during the COVID-19 pandemic. Eur Child Adolesc Psychiatry 2023. https://doi.org/10.1007/s00787-023-02313-6. Spurrier GF, Shulman K, Dibich S, Benoit L, Duckworth K, Martin A. Physical symptoms as psychiatric manifestations in medical spaces: A qualitative study. Front Psychiatry 2023;13. Sewell J. School refusal. Aust Fam Physician 2008;37:406–8. Stone LA, Benoit L, Martin A, Hafler J. Barriers to Identifying Learning Disabilities: A Qualitative Study of Clinicians and Educators. Acad Pediatr 2023;23:1166–74. Ingul JM, Havik T, Heyne D. Emerging School Refusal: A School-Based Framework for Identifying Early Signs and Risk Factors. Cogn Behav Pract 2019;26:46–62. Sibeoni J, Orri M, Podlipski M-A, Labey M, Campredon S, Gerardin P, et al. The Experience of Psychiatric Care of Adolescents with Anxiety-based School Refusal and of their Parents: A Qualitative Study. J Can Acad Child Adolesc Psychiatry 2018;27:39–49. Maynard BR, Heyne D, Brendel KE, Bulanda JJ, Thompson AM, Pigott TD. Treatment for School Refusal Among Children and Adolescents: A Systematic Review and Meta-Analysis. Res Soc Work Pract 2018;28:56–67. Boussand E, Phan O, Benoit L. School refusal and internet gaming disorder in adolescents: Narrative review of literature. Neuropsychiatr Enfance Adolesc 2021;69:241–52. Havik T, Bru E, Ertesvåg SK. Parental perspectives of the role of school factors in school refusal. Emot Behav Difficulties 2014;19:131–53. Carless B, Melvin GA, Tonge BJ, Newman LK. The role of parental self-efficacy in adolescent school-refusal. J Fam Psychol 2015;29:162–70. Kearney CA, Benoit L. Child and Adolescent Psychiatry and Underrepresented Youth With School Attendance Problems: Integration With Systems of Care, Advocacy, and Future Directions. J Am Acad Child Adolesc Psychiatry 2022. https://doi.org/10.1016/j.jaac.2022.03.016. Rosenthal L, Moro MR, Benoit L. Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care. Front Psychiatry 2020;10:942. https://doi.org/10.3389/fpsyt.2019.00942. Martin R, Benoit JP, Moro MR, Benoit L. A Qualitative Study of Misconceptions Among School Personnel About Absenteeism of Children From Immigrant Families. Front Psychiatry 2020;11:202. Bools C, Foster J, Brown I, Berg I. The identification of psychiatric disorders in children who fail to attend school: a cluster analysis of a non-clinical population. Psychol Med 1990;20:171–81. https://doi.org/10.1017/S0033291700013350. Brault C, Thomas I, Moro MR, Benoit L. School refusal in immigrants and ethnic minority groups: a qualitative study of adolescents’ and young adults’ experiences. Front Psychiatry In press. Knollmann M, Reissner V, Kiessling S, Hebebrand J. The differential classification of school avoidance- a cluster-analytic investigation. Z Kinder Jugendpsychiatr Psychother 2013;41:335–45. Kearney CA, Benoit L, Gonçalves C, Heyne D, Melvin G, O’Toole C, et al. School attendance and absenteeism: Toward next-generation common measurement. Child Youth Serv Rev Under Review. Additional Declarations No competing interests reported. Supplementary Files Appendix1SurveyContent.docx Appendix2ClusterComparisons.docx SupplementaryFigures12.docx Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2024 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted Editorial decision: Revision requested 09 Feb, 2024 Reviewers agreed at journal 23 Dec, 2023 Reviews received at journal 12 Dec, 2023 Reviewers agreed at journal 04 Dec, 2023 Reviewers invited by journal 29 Nov, 2023 Editor assigned by journal 17 Oct, 2023 Submission checks completed at journal 17 Oct, 2023 First submitted to journal 16 Oct, 2023 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. 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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-3453432","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":240958007,"identity":"d7c35b08-2276-414d-8f3f-3d1190e01181","order_by":0,"name":"Laelia 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SOCK","lastName":"PENG","suffix":""},{"id":240958009,"identity":"bbe18a45-725a-465d-ba68-e6baf60e37d6","order_by":2,"name":"Julien FLOURIOT","email":"","orcid":"","institution":"Université Paris-Saclay, UVSQ, Inserm U1018, CESP","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Julien","middleName":"","lastName":"FLOURIOT","suffix":""},{"id":240958010,"identity":"9598a4a8-8393-4ea7-983e-cdae0f7b9875","order_by":3,"name":"Madeline DIGIOVANNI","email":"","orcid":"","institution":"Yale School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Madeline","middleName":"","lastName":"DIGIOVANNI","suffix":""},{"id":240958011,"identity":"83d4f512-d8bc-4e03-88a1-1202d5d4d1e1","order_by":4,"name":"Nicolas BONIFAS","email":"","orcid":"","institution":"Ecole Normale Supérieure de 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CESP","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"","lastName":"FALISSARD","suffix":""}],"badges":[],"createdAt":"2023-10-16 15:29:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3453432/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3453432/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00787-024-02419-5","type":"published","date":"2024-04-11T15:01:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44944973,"identity":"1278eedc-6504-46d4-983b-9d135845b6b4","added_by":"auto","created_at":"2023-10-19 18:33:45","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":579931,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFive trajectories of school refusal during the first three years after onset\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3453432/v1/f777addbd99216321f263db6.jpeg"},{"id":54712693,"identity":"f890c483-ace1-4e88-9b40-384a9e859d87","added_by":"auto","created_at":"2024-04-15 15:12:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":663939,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3453432/v1/195b0ee8-822f-468f-86d9-2319b54f8637.pdf"},{"id":44944382,"identity":"8021648a-be95-4ff1-bdbb-281ea82d6bb8","added_by":"auto","created_at":"2023-10-19 18:25:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37486,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1SurveyContent.docx","url":"https://assets-eu.researchsquare.com/files/rs-3453432/v1/e3fd2718b28c4d8e0efaa81f.docx"},{"id":44944384,"identity":"a92c82bb-6e3d-4676-bfa0-600013220867","added_by":"auto","created_at":"2023-10-19 18:25:45","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31235,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2ClusterComparisons.docx","url":"https://assets-eu.researchsquare.com/files/rs-3453432/v1/32d35cf1ad029f61517607dc.docx"},{"id":44944386,"identity":"54c9d491-e78a-4af9-85de-0e306376be62","added_by":"auto","created_at":"2023-10-19 18:25:45","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":322944,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigures12.docx","url":"https://assets-eu.researchsquare.com/files/rs-3453432/v1/d95c896a7547143e74e97845.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trajectories of school refusal: sequence analysis using retrospective parent reports","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSchool attendance problems (SAPs) are associated with increased risk of early and permanent school dropout and of developing psychiatric disorders [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In the longer term, SAPs are linked to economic and social precariousness [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Mounting concern about such consequences has led researchers to better define SAPs in an effort to provide early interventions for affected children [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Most authors use Kearney\u0026rsquo;s criteria for problematic absenteeism to identify children with SAPs, namely: (1) missing at least 25 percent of total school time for at least two weeks; (2) experiencing severe difficulty attending classes for at least two weeks with significant interference in a child\u0026rsquo;s or family\u0026rsquo;s daily routines; and/or (3) being absent for at least 10 days of school during any 15-week period while school is in session [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Heyne et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] differentiated four distinct categories of SAPs: (1) school refusal (SR, compounded by emotional distress); (2) truancy (when the child conceals absenteeism from their parents); (3) school withdrawal (through parental neglect); and (4) school exclusion (through a school decision). In their detailed definition, SR occurs when a young person: (1) is reluctant or refuses to attend school, in conjunction with emotional distress that is usually made manifest by absences, although not necessarily so, as in the case of repeat late arrivals; (2) does not try to hide absences from their parents; (3) does not display antisocial behavior beyond resistance to parental attempts to get them to school; and (4) parents have made reasonable efforts to secure attendance at school [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn non-clinical population, school fear is associated with internalizing problems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The prevalence of SR ranges between 1 and 5%, with no difference across genders [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the DSM-5, SR is often co-occurring, a clinical presentation sometimes associated with social or specific phobias, or with generalized anxiety, major depressive, oppositional defiant, post-traumatic stress, or adjustment disorders, among others [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Three developmental stages have been identified as conducive to SR: between 5 and 6, 10 and 11, [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] or 13 and 15 years of age [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Prolonged absence can compromise learning, socialization, and self-esteem, and thus affect later academic and developmental milestones [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Social phobia and learning difficulties have been found to predict poorer functional outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on a national health survey in France, we conducted a retrospective study based on parental responses. We sought to identify distinctive course and outcome in SR over the first three years of onset.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eIn partnership with the educational policy department of the French Ministry of Education (DGESCO) and with parent representatives from the School Refusal Association (APS), we developed a web-based survey using Lime Survey software [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. APS is a parent-led support group that aims to develop better understanding, recognition, and care of SR. The study was approved by the Ethics Evaluation Committee of the National Institute of Health and Medical Research (Inserm, IRB #00003888).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cp\u003eThe survey was intended for parents who believe their child suffers or has suffered SR, whether formally diagnosed or not (see survey content in \u003cb\u003eAppendix 1\u003c/b\u003e). The survey defined SR upfront: \u0026ldquo;School refusal is reluctance or refusal to attend school, associated with emotional distress\u0026rdquo;. The survey asked 36 questions about the index case: 1) socio-demographic characteristics; 2) SR trajectory (age of onset, course); 3) SR clinical characteristics (symptoms, associated diagnoses) 4) clinical care and 5) school flexibility. We did not collect any personally identifying information.\u003c/p\u003e \u003cp\u003eSR course after onset was assessed from retrospective recollection of school attendance and emotional distress from ages 5 to 20 years old. Question #15 began with the stem \"This year my child was:\" and provided eight forced-answer choices: \"Present all year and comfortable at school,\" \"Present all year but felt poorly at school,\u0026rdquo; \"Absent for less than two weeks,\" \"Absent between two and four weeks,\" \"Absent more than a month but less than one trimester,\" \"Absent one trimester,\" \"Absent two trimesters,\" or \"Absent throughout the school year.\" Our inclusion criterion was \u0026ge;\u0026thinsp;2 school week absences for at least one year [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We defined SR onset as the child\u0026rsquo;s age at the time of their first school absence lasting at least two weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eBetween May and October 2018, a link to the anonymous survey was deployed by: 1) DGESCO, through the superintendents of six major educational regions; and 2) APS, through its private Facebook page, followed by 4,542 individuals by the end of the data collection interval. The investigators did not have access to email addresses, the private Facebook group, or any personally identifying data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe compared continuous and categorical variables using ANOVA and Fisher\u0026rsquo;s Exact Test, respectively. We calculated two-sided p-values with a significance threshold of \u0026lt;\u0026thinsp;0.05. To refine comparisons between clusters for variables on which the Fisher Exact Test showed that at least one cluster is significantly different from the others (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), we tried all possible groupings of clusters in two macro-groups and looked for statistically significant differences (see \u003cb\u003eAppendix 2\u003c/b\u003e). Given the exploratory nature of this study, we did not correct for multiple comparisons. We analyzed descriptive variables using R (Version 3.6.0) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo determine school refusal trajectories, we used sequence analysis, which aims to identify similar series of successive states (\"standard sequences\") within a corpus of sequences [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Sequence analysis is a non-parametric cluster analysis technique, also called unsupervised clustering technique. Unsupervised clustering is exploratory by nature as the induction of data is automated and based on disaggregated data. As such, variables are not selected: all variables are tested in this large-scale exploratory statistical method. Unsupervised clustering is increasingly used in medicine, including in mental health research, to decompose the heterogeneity of clinical presentations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It can be used safely on a large sample, as it is the case in this study.\u003c/p\u003e \u003cp\u003eWe formed clusters using sequence analysis on the variable \"This year my child was\" for the 3 years after the beginning of SR (including the year of onset), for the subsample of children for whom school attendance data were available for a minimum of three years after SR onset. Each trajectory was considered a unique sequence within a finite number of possibilities, i.e. the eight forced-choice responses. We calculated sequence similarity using the optimal matching algorithm of the TraMineR package (version 2.0-11.1) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We calculated a substitution matrix by converting the eight absenteeism modalities to their equivalent in days and then calculating the difference in days when moving from one state to another. We used the Hubert C index (HC) from the R Weighted Cluster library (version 1.4) to assess the quality of the clusters we obtained. HC compares the partition obtained to the theoretically best partition possible for a given number of groups. The closer the HC is to 0, the more adequate the clusters [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We then described the resulting clusters using variables from the following categories: 1) socio-demographics; 2) SR characteristics; 3) clinical care; and 4) school flexibility.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eThe survey link was opened on 2,511 instances, yielding 1,970 complete responses, 1,413 (73%) of them meeting the definition of SR. We excluded 85 (6%) responses completed by adult subjects who had suffered from SR in their childhood. The analysis included 1,328 parental responses, with 1,274 (96%) by mothers. We assessed the relevance of our definition of SR: among the 1328 responses included, 99% children displayed at least one criterion that distinguishes SR from other SAPs (i.e., anxiety, panic attacks). Genders were equally distributed (49% female). At the time of questionnaire completion, mean subject age was 14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 years, 887 subjects (67%) had partnered or married parents, and 907 (69%) lived with both parents at the time of SAP onset. Parents\u0026rsquo; education level was higher than the national average: 679 (51%) had a diploma equivalent or more than 2 years of post-graduate study, compared to 22% in the general French population, ages 25 to 64 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Most families (n\u0026thinsp;=\u0026thinsp;1231, 93%) only spoke French at home.\u003c/p\u003e \u003cp\u003eMean age of SR onset was 13\u0026thinsp;\u0026plusmn;\u0026thinsp;4 years. During the two years preceding onset, 323 children (24%) had experienced serious illness or the death of a loved one, 311 (23%) a change of school, 213 (16%) a move, and 157 (12%) a change in family organization. Additionally, 823 (62%) experienced some form of pressure from school, their parents, and/or themselves, 634 (48%) been victims of bullying, insults, or threats, and 206 (16%) of physical violence. Prodromal presentations such as oppositional, depressive, anxious, or somatic symptoms were first evident upon or in anticipation of attending school, at a mean age of 8\u0026thinsp;\u0026plusmn;\u0026thinsp;4 years. Risky screen use was reported by 691 participants (52%). SR was associated with at least one other diagnosis among 1,167 children (88%). The most frequent conditions were depression (n\u0026thinsp;=\u0026thinsp;425, 33%) and social phobia (n\u0026thinsp;=\u0026thinsp;367, 28%). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for further details.\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\u003eSchool refusal characteristics in the survey sample (n\u0026thinsp;=\u0026thinsp;1,328)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1,328\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSR definition: \u0026gt; 2 weeks of school absenteeism with emotional distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,328 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 distinctive criterion of SR: diagnosis of SR by a health care provider; panic attacks; anxiety; stomachaches; headaches; sleep problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,309 (99)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSchool refusal characteristics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis of SR by a health care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e930 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManifestations related to school attendance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePanic attacks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,125 (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e912 (68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomachaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1079 (81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e811 (61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e837 (63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnger\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e338 (26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents\u0026rsquo; perception of risky use of screens (smartphone, video games, social networks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e691 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e671 (51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparation anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e503 (38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eComplaints toward:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e459 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassmates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e338 (26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeachers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e302 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrop in academic performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e399 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArguments with authority figures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e388 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 associated condition diagnosed by a care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,167 (88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e425 (33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Phobia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e367 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning disability (e.g., dyslexia, dyspraxia, dysgraphia, dyscalculia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention-Deficit/Hyperactivity Disorder (ADHD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggravation of preexisting medical conditions (e.g., asthma, diabetes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEating disorder (i.e., anorexia, bulimia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized Anxiety Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBipolar disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObsessive Compulsive Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship with professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSense of understanding: kindness and availability of at least some interlocutors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e908 (68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1040 (78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSense of rejection: criticism, threat, judgments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e354 (27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eValues represent n (%), unless noted otherwise.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eINSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e ABOUT HERE\u003c/h2\u003e \u003cp\u003eRegarding school adaptations, 759 children (61%) had adjusted school schedules (such as reduced timetables or personal support plans), and 354 parents (27%) felt rejected or criticized by school professionals. Half of the children (n\u0026thinsp;=\u0026thinsp;681, 54%) received at least one pharmacological treatment, and for 546 (44%), the first health professional consulted was their family doctor. Half of the families spent more than 150 euros/month in non-reimbursed care (min\u0026thinsp;\u0026le;\u0026thinsp;med\u0026thinsp;\u0026le;\u0026thinsp;max: 0\u0026thinsp;\u0026le;\u0026thinsp;150\u0026thinsp;\u0026le;\u0026thinsp;3000), and 912 (69%) parents adjusted their work schedules to adapt to their child's SR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTrajectories of school refusal during the first three years after onset\u003c/h2\u003e \u003cp\u003eRetrospective recall of school attendance during the first three years after SR onset was provided for 729 (55%) subjects. Individual trajectories of SR during this time are represented in \u003cb\u003eSupplementary Fig.\u0026nbsp;1\u003c/b\u003e using \u003cem\u003edendrograms\u003c/em\u003e, tree diagrams depicting taxonomic relationships. Absences of less than two weeks or between two weeks and one month were observed among 211 (29%) and 175 (24%) children during the second and third year after SR onset, respectively. Complete return to school and return to school with discomfort were observed among 124 (17%) and 146 (20%) children during the second and third years, respectively.\u003c/p\u003e \u003cp\u003eWe set the optimal number of clusters at five, following the optimal matching algorithm (\u003cb\u003eSupplementary Fig.\u0026nbsp;2\u003c/b\u003e). An HC of 0.1 confirmed the robustness of fit for these five clusters. Children\u0026rsquo;s individual trajectories of SR according to each cluster are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eINSERT FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e ABOUT HERE\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of five SR trajectory clusters\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows socio-demographic characteristics, SR characteristics, associated diagnoses, characteristics of care and school flexibility across the five clusters. Age of onset was lower in Clusters 1 and 2, \u0026ldquo;children,\u0026rdquo; than in clusters 3, 4, and 5 \u0026ldquo;adolescents\u0026rdquo; (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\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 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample characteristics, clinical care, and school flexibility across five school refusal trajectories (n\u0026thinsp;=\u0026thinsp;729)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCluster\u003c/p\u003e \u003cp\u003eDescription\u003c/p\u003e \u003cp\u003e(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003eBeaded absences \u003c/p\u003e \u003cp\u003e(272)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003eRapid \u003c/p\u003e \u003cp\u003erecovery\u003c/p\u003e \u003cp\u003e(132)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003eProlonged recovery\u003c/p\u003e \u003cp\u003e(93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003eGradual\u003c/p\u003e \u003cp\u003edecline\u003c/p\u003e \u003cp\u003e(89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003eRapid\u003c/p\u003e \u003cp\u003edecline\u003c/p\u003e \u003cp\u003e(143)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003esample\u003c/p\u003e \u003cp\u003e(729)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCluster Comparisons\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOdd Ratio\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic characteristics\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 \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex: male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e368 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchool refusal characteristics\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 \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at onset (\u0026gt;\u0026thinsp;2 weeks of absence): mean years (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplaints toward School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e253 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,4} \u0026gt; {3,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplaints toward Teachers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e170 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,4} \u0026gt; {3,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplaints toward Classmates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e187 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,4} \u0026gt; {3,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnger about going to school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e187 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{4} \u0026gt; {1,2,3,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOpposition: Refusal to attend appointments or hostility toward authority figures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e529 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,4,5} \u0026gt; {3}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{4} \u0026gt; {1,2,3,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e189 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e453 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1} \u0026gt; {2,3,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomachaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e115 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e614 (84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1} \u0026gt; {2,3,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender identity issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2,3,5} \u0026gt; {1,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssociated diagnoses\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 \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAggravation of preexisting medical conditions (e.g., asthma, diabetes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,3,4} \u0026gt; {5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2} \u0026gt; {1,3,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLearning disability (e.g., dyslexia, dyspraxia, dysgraphia, dyscalculia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e174 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2,3} \u0026gt; {4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,2} \u0026gt; {3,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial phobia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e236 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical care\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 \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSR diagnosis by a health care provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e118 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e543 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3} \u0026gt; {1,2,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,5} \u0026gt; {1,2,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up by a psychiatrist / child and adolescent psychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e112 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e506 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenounced some care for financial or organizational reasons (ns)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e394 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of care appointments: at least once a week *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e206 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ens\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychotherapy (\u0026gt;\u0026thinsp;1 type): individual; family; group therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e220 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInpatient hospitalization (in psychiatry or pediatrics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e193 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychotropic medication\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 \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntidepressant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e277 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntipsychotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived as efficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e114 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3} \u0026gt; {1,2,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1 type: antidepressant; anxiolytic; sleeping pill; ADHD medication; antipsychotic; herbal anxiolytic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e215 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,3,4,5} \u0026gt; {2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJudicial involvement or protective service report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e103\u0026nbsp;(14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{4,5} \u0026gt; {1,2,3}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSeparation of children from parents suggested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e181 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{3,4,5} \u0026gt; {1,2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchool flexibility\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 \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSchool accommodation (reduced timetable, personal support plan)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e291 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2,3,4,5} \u0026gt; {1}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2,3,4} \u0026gt; {1,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange of school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e341 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2,3,4,5} \u0026gt; {1}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHome schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e176 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{4,5} \u0026gt; {1,2,3}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\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 \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{5} \u0026gt; {1,2,3,4}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeeting with the education officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e736 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{1,3,4,5} \u0026gt; {2}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship with school: Sense of rejection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e254 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e{2} \u0026gt; {1,3,4,5}\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eValues represent n (%), unless noted otherwise. * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026le;\u0026thinsp;0.001. For cluster comparisons, we reported only results with the lowest p-value and sorted them out from the highest odd-ratio to the lowest.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eINSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e ABOUT HERE\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eClusters 1 and 2: Young children\u003c/h2\u003e \u003cp\u003eThe average age of onset for children in clusters 1 and 2 was respectively 9\u0026thinsp;\u0026plusmn;\u0026thinsp;3 years and 10\u0026thinsp;\u0026plusmn;\u0026thinsp;3 years, the youngest clusters in this study (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These children were more likely to have a diagnosis of learning disabilities (OR\u0026thinsp;=\u0026thinsp;1.78, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than participants in clusters 3, 4 and 5. They were less likely to receive follow-up by a psychiatrist or a child psychiatrist (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), antidepressants (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and multiple psychotropic medications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), than children in clusters 3, 4 and 5.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCluster 1: Beaded absences\u003c/h2\u003e \u003cp\u003eThis cluster, the largest (n\u0026thinsp;=\u0026thinsp;272, representing 37% of all respondents), describes a moderate, stable course over the first three years, with young children presenting with only short-term absences. Almost all children in cluster 1 (n\u0026thinsp;=\u0026thinsp;267, 98%) had at least one somatic symptom. They were more likely to experience stomachaches (n\u0026thinsp;=\u0026thinsp;289; 91%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR\u0026thinsp;=\u0026thinsp;2.57) and headaches (n\u0026thinsp;=\u0026thinsp;189; 70%, p\u0026thinsp;=\u0026thinsp;0.001, OR\u0026thinsp;=\u0026thinsp;1.66) than the four other clusters. The latter were more likely to benefit from school accommodations (OR\u0026thinsp;=\u0026thinsp;1.67, p\u0026thinsp;=\u0026thinsp;0.001) or a change of school (OR\u0026thinsp;=\u0026thinsp;1.66, p\u0026thinsp;=\u0026thinsp;0.001), than children in cluster 1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCluster 2: Rapid recovery\u003c/h2\u003e \u003cp\u003eThis profile encompasses a high proportion of children with existing medical problems who tended to return to school by the second year of follow-up. In this cluster (n\u0026thinsp;=\u0026thinsp;132), SR was associated with a worsening of preexisting medical conditions more frequently (17%) than in the four other clusters (n\u0026thinsp;=\u0026thinsp;23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The three most common preexisting medical conditions were asthma, rare and/or chronic diseases, and digestive problems. Compared to the four other clusters, parents in cluster 2 reported more frequently not having met the education officer (OR\u0026thinsp;=\u0026thinsp;1.72, p\u0026thinsp;=\u0026thinsp;0.003) and feeling rejected by the school (n\u0026thinsp;=\u0026thinsp;54, 41%, OR\u0026thinsp;=\u0026thinsp;1.71, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eIf considered together with cluster 4, participants in cluster 1 and 2 reported higher levels of complaints toward school (OR\u0026thinsp;=\u0026thinsp;1.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), teachers (OR\u0026thinsp;=\u0026thinsp;2.48; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and classmates (OR\u0026thinsp;=\u0026thinsp;2.56; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than participants in clusters 3 and 5.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCluster 3, 4, and 5: Adolescents\u003c/h2\u003e \u003cp\u003eIn clusters 3, 4 and 5, encompassing older children, participants were more likely to receive psychiatric follow-up (OR\u0026thinsp;=\u0026thinsp;2.16, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a diagnosis of social phobia (OR\u0026thinsp;=\u0026thinsp;1.87, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), antidepressant medication (OR\u0026thinsp;=\u0026thinsp;2.06, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or multiple medication (OR\u0026thinsp;=\u0026thinsp;1.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than children in clusters 1 and 2. A separation of children from parents was more likely to be suggested for these three clusters (OR\u0026thinsp;=\u0026thinsp;2.19, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than for participants in clusters 1 and 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCluster 3: Prolonged recovery\u003c/h2\u003e \u003cp\u003eFor this cluster, SR onset was on average at age 12\u0026thinsp;\u0026plusmn;\u0026thinsp;3. Children in the four other clusters were more likely to display oppositional behavior than the ones in cluster 3 (OR\u0026thinsp;=\u0026thinsp;1.92, p\u0026thinsp;=\u0026thinsp;0.003). Contrary to clusters 4 and 1, children in clusters 2, 3 and 5 were more likely to question their gender identity, although still infrequently (OR\u0026thinsp;=\u0026thinsp;4.32, p\u0026thinsp;=\u0026thinsp;0.004). Participants in cluster 3 obtained a formal SR diagnosis more often than other clusters (87%, n\u0026thinsp;=\u0026thinsp;81, OR\u0026thinsp;=\u0026thinsp;2.54; p\u0026thinsp;=\u0026thinsp;0.001) and were more likely to perceive medication as helpful (n\u0026thinsp;=\u0026thinsp;24, 26%, OR\u0026thinsp;=\u0026thinsp;2.11, p\u0026thinsp;=\u0026thinsp;0.005). These children may have benefited from an intensive healthcare response: 35% of them had at least one care appointment per week (n\u0026thinsp;=\u0026thinsp;33, p\u0026thinsp;=\u0026thinsp;0.02, cluster comparison\u0026thinsp;=\u0026thinsp;ns) and they were less likely to forego care for financial or organizational reasons (n\u0026thinsp;=\u0026thinsp;41, 44%, ns).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCluster 4: Gradual decline\u003c/h2\u003e \u003cp\u003eSR started on average at 11\u0026thinsp;\u0026plusmn;\u0026thinsp;3 years for the children in this cluster (n\u0026thinsp;=\u0026thinsp;89, representing 12% of respondents). They maintained partial school attendance during the first two years, followed by cessation during the third. In comparison to the four other clusters, children in this cluster were more frequently angry about going to school (n\u0026thinsp;=\u0026thinsp;36, 40%, OR\u0026thinsp;=\u0026thinsp;2.2, p\u0026thinsp;=\u0026thinsp;0.001), and more likely to express oppositional behavior (n\u0026thinsp;=\u0026thinsp;52, 58%, OR\u0026thinsp;=\u0026thinsp;1.78, p\u0026thinsp;=\u0026thinsp;0.008). As mentioned above, participants in clusters 1, 2 and 4 complained more frequently about their school, teachers, and classmates than children in clusters 3 and 5.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCluster 5: Rapid decline\u003c/h2\u003e \u003cp\u003eIn this profile, with an age of onset at 12\u0026thinsp;\u0026plusmn;\u0026thinsp;2 years, school absenteeism persisted despite accommodations and medical monitoring. This cluster was the most likely to report social phobia, 44% (n\u0026thinsp;=\u0026thinsp;63, OR\u0026thinsp;=\u0026thinsp;1.88, p\u0026thinsp;=\u0026thinsp;0.001). Children in this group had an intensive healthcare response. Compared to the four other clusters, participants in this cluster were more likely to receive more than one type of psychotherapy (44%, n\u0026thinsp;=\u0026thinsp;63, OR\u0026thinsp;=\u0026thinsp;2.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), to having been hospitalized in a psychiatry or pediatric unit (38%, n\u0026thinsp;=\u0026thinsp;54, OR\u0026thinsp;=\u0026thinsp;1.95, p\u0026thinsp;=\u0026thinsp;0.001), and to receive antipsychotic prescriptions (10%, n\u0026thinsp;=\u0026thinsp;15, OR\u0026thinsp;=\u0026thinsp;3, p\u0026thinsp;=\u0026thinsp;0.002). This cluster featured the highest frequency of homeschooling, for 38% of participants (n\u0026thinsp;=\u0026thinsp;55, OR\u0026thinsp;=\u0026thinsp;2.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among these adolescents, a separation from parents was more likely to be suggested than in the four other clusters (OR\u0026thinsp;=\u0026thinsp;2.28, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIf considered together, participants in clusters 4 and 5 were more likely to feature homeschooling (OR\u0026thinsp;=\u0026thinsp;2.75, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and to be subject to judicial or social services report (OR\u0026thinsp;=\u0026thinsp;2.1, p\u0026thinsp;=\u0026thinsp;0.001) than children in clusters 1, 2 or 3.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLatent profiles\u003c/h2\u003e \u003cp\u003eBy acknowledging the varied factors associated with each subtype of SR, this common clinical presentation can be divided into more comprehensible, discrete patterns for parents, educators, and healthcare providers to identify. Through pattern recognition, such a typology could help with timely identification of SR and implementation of evidence-based interventions to optimize SR outcomes.\u003c/p\u003e \u003cp\u003eAcross all profiles, parents reported how their children\u0026rsquo;s attendance problems were frequently associated with related conditions, ranging from bullying, depression, social phobia, or gender identity issues. Somatic complaints were also common across profiles, in keeping with existing literature [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The high frequency of these concurrent concerns is arguably unique to SR within the broader domain of SAPs, as the definition of SR encompasses the child\u0026rsquo;s emotional distress [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. SR may appear less stigmatizing than other SAPs and thus have an element of desirability for parents attempting to make sense of a difficult situation.. Nevertheless, the \u0026ldquo;long recovery\u0026rdquo; profile reports rapid medical and school support, echoing existing evidence suggesting that early and intensive care is associated with more favorable outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eParental involvement and school flexibility\u003c/h2\u003e \u003cp\u003eWe found that a high degree of parental involvement may be associated with a better outcome, but only for certain interventions. Adaptation of parental work schedule was frequently reported across profiles. Alternatively, home-schooling was significantly higher for the two groups with more negative outcomes (\u0026ldquo;progressive worsening\u0026rdquo; and \u0026ldquo;rapid worsening\u0026rdquo;). Homeschooling may be a consequence of a prolonged absence, but this association may also be confounded by age: the average age of favorable profiles was lower than of unfavorable profiles, suggesting that the benefit may be a function of earlier intervention. Also, home schooling requires self-discipline and may therefore not be offered to younger children.\u003c/p\u003e \u003cp\u003eTo support parents\u0026rsquo; efforts, schools serve as a second pillar in supporting favorable outcomes. School accommodations were least frequently reported for younger children, in the \u0026ldquo;beaded absences\u0026rdquo; and \u0026ldquo;rapid recovery\u0026rdquo; profiles. The \u0026ldquo;rapid recovery\u0026rdquo; profile was more likely to be associated with a physical illness or learning disability rather than psychiatric illness, suggesting that the intensity of school intervention may not be as significant for these children as for other profiles, instead favoring treatment of the underlying medical or learning condition [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In response to the high frequency of visits to the school nurse, as reported in this study, school-based attendance teams have been recommended to improve detection of risk factors for SR by monitoring students\u0026rsquo; emotional distress, somatic symptoms, and parental motivations for absence [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eThe role of healthcare providers\u003c/h2\u003e \u003cp\u003eHealthcare providers are a third key stakeholder for children dealing with SR, and can provide additional screening, treatment, and advocacy for the conditions that contribute to SR. Nearly half of our sample had their first point of contact for SR with their family physician, and the overwhelming majority reported at least one associated diagnosis. Healthcare providers can support parents and schools by tailoring their approach according to SR subtype. For younger patients, SR may be more likely related to physical illness, so diagnosis of a physical illness at a doctor\u0026rsquo;s visit can include conversations with parents and schools about how to minimize distress and disruptions to school attendance. For older patients, healthcare providers can act as advocates between the school and mental health systems to address bullying, incorporate flexible school schedules, and recommend intensive mental health care.\u003c/p\u003e \u003cp\u003eRegarding specific profiles, psychiatric medication use was more common for the older three profiles than for the younger two, as was follow-up with a psychiatrist, further suggesting a distinction between the younger child/medical or learning comorbidity-associated profiles, and the older child/psychiatric comorbidity-associated profiles. The \u0026ldquo;long recovery\u0026rdquo; profile, with high rates of diagnosis by a care provider, frequent appointments, and high satisfaction regarding medication, was associated with an eventual successful return to school after intensive support. Interestingly, psychiatric hospitalization was more frequent for the older profiles, but was not associated with any clear benefit for resolving SR. Qualitative research of psychiatric healthcare for adolescents struggling with SR suggests that adolescents find mental healthcare valuable in assisting with self-transformation and problem-solving abilities [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, a meta-analysis of the existing treatments for SR demonstrates that most interventions focus on cognitive behavioral therapy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Together, these findings may explain the limited association of hospitalization and return to school demonstrated in this study: Acute hospitalizations may be more likely to focus on crisis stabilization rather than on the longer-term psychological coping that appears to be most valued and effective by adolescents.\u003c/p\u003e \u003cp\u003eAn additional point of intervention for healthcare workers is to monitor screen time: Risky screen use was reported by most participants across clusters. Increased screen time questions family functioning as a trigger or maintenance factor in SR [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and therefore screen time monitoring should arguably include an assessment of the family\u0026rsquo;s ability to be engaged in the child\u0026rsquo;s trajectory. On the other hand, given that nearly a third of participants reported a feeling of rejection or criticism by the schools as relevant to their child\u0026rsquo;s trajectory, it is paramount that healthcare providers first build rapport with families to support them in being engaged with their child\u0026rsquo;s school trajectory, to avoid coming across as judgmental or intrusive. Parents of school-refusing children have already been shown to perceive a lack of understanding from schools in addressing their children, and the same dynamic should be avoided in healthcare [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Potential interventions may also focus on parental self-efficacy, a concept shown to be implicated in SR, although not quite predictive once controlling for child or parent comorbidities [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eUnderrepresented minorities with SR\u003c/h2\u003e \u003cp\u003eThe vast majority of children in this study only spoke French at home, illustrating a known difficulty in accurately characterizing the SAP of children of underrepresented families (immigrants, ethnic minorities) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] due to both a lack of representation in parental support groups and a mischaracterization of students\u0026rsquo; and parents\u0026rsquo; behaviors [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Indeed, the definition of parental \u0026ldquo;reasonable efforts\u0026rdquo; has been criticized for being left to the interpretation of professionals [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Nevertheless, parents from underrepresented groups may experience difficulties in communicating their concerns to school personnel [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which may lead SR to be categorized as truancy or school withdrawal instead [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Similarly, young people from underrepresented groups experiencing emotional distress can feel ashamed to ask for help [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], leading to the conflation of truancy and SR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe acknowledge several limitations, the main one being the retrospective nature of this study. This study describes associations only, and therefore we cannot make any causative claims about what features of a trajectory are protective or harmful for a given child profile, limiting the strength of recommendations for future practice. Of note, we did not make corrections for the number of tests performed given the exploratory nature of this study. This study uses an unsupervised clustering technique, which requires a large sample. Therefore, further confirmatory studies should include a large sample. Alternatively, previous studies about school absenteeism [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] based on smaller samples used instead an inductive cluster analysis technique, in which different time patterns are first identified, then used as one variable.\u003c/p\u003e \u003cp\u003eParticipants were invited based on self-identification, not by formal delineation of SR versus other SAP, so it is unclear whether children described in this sample truly suffer from SR, as opposed to truancy, school withdrawal, or school exclusion. To more reliably characterize the subtypes of attendance problems, screening instruments are being developed and once validated may guide future studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Also, we noted a high frequency of parental involvement in our sample: Parents who are more involved may be more likely to participate in such a study. It is important to note that parental flexibility is a resource that not all children have access to; in our sample most children lived with both parents, who had higher employment and education metrics than average, such that this study does not adequately characterize the population of children without these presumably protective factors. This study may not accurately characterize the SAP of children of minority families due to their underrepresentation in the survey sample. Finally, future studies could explore the SR profiles based not only on parental reporting but on child self-reporting.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This study on subtypes of SR trajectories based on parental perspectives emphasizes seeking support for the distress central to SR. We hope our findings can help inform tailored supports for each profile of SR from three key stakeholders: parents, schools, and healthcare workers. A sense of trust and non-judgment between families, schools, and other providers is key toward creating an environment for children to remain engaged in their education and to cope with stressors in an adaptive way.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to the crowd-funding platform Thellie, to private donors, and to the Jasmin Roy Foundation for their financial support. The Federation of the CMPP (Centre M\u0026eacute;dico Psycho P\u0026eacute;dagogiques) and the Association Phobie Scolaire were helpful partners by sharing the link to the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Ethics Review Committee of the French National Institute of Health and Medical Research (Inserm, IRB #00003888).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKearney CA. School absenteeism and school refusal behavior in youth: A contemporary review. 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J Fam Psychol 2015;29:162\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eKearney CA, Benoit L. Child and Adolescent Psychiatry and Underrepresented Youth With School Attendance Problems: Integration With Systems of Care, Advocacy, and Future Directions. J Am Acad Child Adolesc Psychiatry 2022. https://doi.org/10.1016/j.jaac.2022.03.016.\u003c/li\u003e\n\u003cli\u003eRosenthal L, Moro MR, Benoit L. Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care. Front Psychiatry 2020;10:942. https://doi.org/10.3389/fpsyt.2019.00942.\u003c/li\u003e\n\u003cli\u003eMartin R, Benoit JP, Moro MR, Benoit L. A Qualitative Study of Misconceptions Among School Personnel About Absenteeism of Children From Immigrant Families. Front Psychiatry 2020;11:202.\u003c/li\u003e\n\u003cli\u003eBools C, Foster J, Brown I, Berg I. The identification of psychiatric disorders in children who fail to attend school: a cluster analysis of a non-clinical population. Psychol Med 1990;20:171\u0026ndash;81. https://doi.org/10.1017/S0033291700013350.\u003c/li\u003e\n\u003cli\u003eBrault C, Thomas I, Moro MR, Benoit L. School refusal in immigrants and ethnic minority groups: a qualitative study of adolescents\u0026rsquo; and young adults\u0026rsquo; experiences. Front Psychiatry In press.\u003c/li\u003e\n\u003cli\u003eKnollmann M, Reissner V, Kiessling S, Hebebrand J. The differential classification of school avoidance- a cluster-analytic investigation. Z Kinder Jugendpsychiatr Psychother 2013;41:335\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eKearney CA, Benoit L, Gon\u0026ccedil;alves C, Heyne D, Melvin G, O\u0026rsquo;Toole C, et al. School attendance and absenteeism: Toward next-generation common measurement. Child Youth Serv Rev Under Review.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"school refusal, outcome, course, sequence analysis, school attendance problems, trajectories","lastPublishedDoi":"10.21203/rs.3.rs-3453432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3453432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSchool refusal (SR) is a form of school attendance problem (SAP) that requires specific mental health care. Despite improvements in the definition of SAPs, the course of SR is not well characterized.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTo explore three-year patterns of SR course in children, as reported by their parents, we deployed an anonymous web-based survey. We defined SR onset as the absence of \u0026ge;\u0026thinsp;2 school weeks during one academic year, combined with emotional distress. We defined standard SR trajectories using sequence analysis of parents\u0026rsquo; recollection of three consecutive years of school attendance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe obtained 1,970 responses, 1,328 (67%) completed by a parent and meeting the definition of SR. Of these, 729 (55%) responses included three years of school attendance recollection. We identified five prototypical trajectories of SR: two profiles for children: \u003cem\u003ebeaded absences\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;272), and \u003cem\u003erapid recovery\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;132); and three for adolescents: \u003cem\u003eprolonged recovery\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;93), \u003cem\u003egradual decline\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;89), and \u003cem\u003erapid decline\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;143).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found five distinct trajectories of retrospective recall of SR course. Through pattern recognition, this typology could help with timely identification of SR and implementation of evidence-based interventions to optimize outcomes. Prospective replication of these findings and their field application is warranted.\u003c/p\u003e","manuscriptTitle":"Trajectories of school refusal: sequence analysis using retrospective parent reports","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-19 18:25:40","doi":"10.21203/rs.3.rs-3453432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-09T11:16:07+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"d95201ae-6aec-4d12-98f8-a0e5b36672dc","date":"2023-12-23T20:15:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-12-12T13:43:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c6910994-b479-4d06-9970-66c696186da2","date":"2023-12-04T13:00:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-11-29T16:41:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-18T03:38:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-18T03:38:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2023-10-16T15:14:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7bb6d684-fd4a-4cab-8760-e2cde5b25f70","owner":[],"postedDate":"October 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-15T15:04:58+00:00","versionOfRecord":{"articleIdentity":"rs-3453432","link":"https://doi.org/10.1007/s00787-024-02419-5","journal":{"identity":"european-child-and-adolescent-psychiatry","isVorOnly":false,"title":"European Child \u0026 Adolescent Psychiatry"},"publishedOn":"2024-04-11 15:01:41","publishedOnDateReadable":"April 11th, 2024"},"versionCreatedAt":"2023-10-19 18:25:40","video":"","vorDoi":"10.1007/s00787-024-02419-5","vorDoiUrl":"https://doi.org/10.1007/s00787-024-02419-5","workflowStages":[]},"version":"v1","identity":"rs-3453432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3453432","identity":"rs-3453432","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}