Abstract
Self-harm and suicidal ideation in children and adolescents are common and are risk factors for completed suicide. Social exclusion, which can take many forms, increases the risk of self-harm and suicidal ideation. One important marker of social exclusion in young people is school absenteeism. Whether school absenteeism is associated with these adverse outcomes, and if so to what extent, remains unclear. To determine the association between school absenteeism and both self-harm (including completed suicide) and suicidal ideation in children and adolescents, we conducted a systematic review of observational studies. We conducted meta-analysis and report a narrative synthesis where this was not possible. Meta-analysis of cross-sectional studies showed that school absenteeism was associated with an increased risk of self-harm [pooled adjusted odds ratio (aOR) 1.37, 95% confidence interval 1.20–1.57, P = 0.01] and of suicidal ideation (pooled aOR 1.20, 95% CI 1.02–1.42, P = 0.03). A small number of studies showed that school absenteeism had a longitudinal association with both adverse outcomes. Heterogeneity in the exposure and outcome variables, study design and reporting was prominent and limited the extent to which it was appropriate to pool results. School absenteeism was associated with both self-harm and suicidal ideation in young people, but this evidence was derived from a small number of cross-sectional studies. Further research into the mechanisms of this association could help to inform self-harm and suicide prevention strategies at clinical, school and population levels.
Highlights
Suicide remains the second most common cause of death in young people aged 10–24 years [1–3]
We found some studies that did not detect an association and some that reported an inverse association, when combinable effect estimates from multivariate analyses were pooled in meta-analyses, we detected a 20% increase in odds of suicidal ideation and a 37% increase in odds of self-harm for those with school absenteeism
The absence of a difference between groups in the single study which compared those with multiple compared to single suicide attempts suggests that school absenteeism may be associated with the presence of self-harm behaviour, it may not be associated with an increase in severity or frequency [42]
Summary
Suicide remains the second most common cause of death in young people aged 10–24 years [1–3]. There are a number of established risk factors for self-harm and suicidal behaviour in young people, including mental disorders such as depression, anxiety, attention deficit and hyperactivity disorder (ADHD) and conduct disorder, drug and alcohol misuse and personality characteristics such as impulsivity. Social factors such as low socioeconomic status, adverse childhood experiences, family discord and bullying are known to be risk factors [7–9]. Restricted educational achievement and the absence of a feeling of ‘school connectedness’ seem to be related to self-harm [5, 10], but other educational factors, including school attendance, which may be pertinent in this age group, are yet to be explored in any detail. This is surprising, given that schools collect substantial amounts of data about educational factors, such as attendance, attainment and exclusions
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