A Potential Vicious Cycle between School Refusal and Depression among Chinese Adolescents: A Cross-Lagged Panel Model Analysis

Background: Adolescent depression and school refusal (SR) are prevalent and important global concerns that need to be understood and addressed. Cross-sectional associations have been reported but prospective relationships between them remain unclear. This longitudinal study investigated the bidirectional relationships between these two problems among Chinese adolescents. Methods: A longitudinal study was conducted in Taizhou, China, surveying students of three junior high schools, three senior high schools, and one vocational high school. A total of 3882 students completed the questionnaire at baseline (T1); 3167 of them completed an identical follow-up questionnaire after 6 months (T2). Depression was assessed via the Patient Health Questionnaire (PHQ-9) and SR via the modified Chinese version of The School Refusal Assessment Scale-Revised (SRAS-R). Cross-lagged panel modeling (CLPM) analysis was conducted to test the reciprocal relationships, adjusting for socio-demographic factors. Multiple group analysis was conducted to test whether the CLPM differed by gender and grade. Results: Statistically significant bidirectional relationships were found. A higher level of SR assessed at T1 is prospectively associated with a higher level of depression at T2 (β = 0.07, p = 0.006); a higher level of depression at T1 also is prospectively associated with a higher level of SR at T2 (β = 0.14, p < 0.001). Such models differed significantly by neither gender nor grade. Conclusion: SR and depression should be seen as each other’s mutually reinforcing association. The bidirectional relationships potentially result in a vicious cycle. Early interventions may target both problems concurrently. Future studies may involve more time points and test some mediators.