Open Access

ARTICLE

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

Xiaojun Xu^1,#, Hui Lu^2,#, Mengni Du³, Yang Wang^1,4, Mingyan Liu², Lei Qian^1,5, Chunyan Shan¹, Jianan Xu⁶, Yanqiu Yu⁷, Guohua Zhang⁴, Anise M. S. Wu^8,9, Joseph T. F. Lau^1,4,10,*, Deborah Baofeng Wang^1,*

1 Zhejiang Provincial Clinical Research Center for Mental Health, The Affiliated Wenzhou Kangning Hospital, Wenzhou Medical University, Wenzhou, 325000, China
2 Key Laboratory of Alzheimer’s Disease of Zhejiang Province, Institute of Aging Wenzhou Medical University, Oujiang Laboratory (Zhejiang Laboratory for Regenerative Medicine, Vision, and Brain Health), Wenzhou, 325035, China
3 Teaching and Research Center, Bureau of Education, Linhai, Taizhou, 317000, China
4 School of Mental Health, Wenzhou Medical University, Wenzhou, 325015, China
5 Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada
6 Department of Psychology, University of Toronto, Scarborough, ON M5S 1A1, Canada
7 School of Public Health, Fudan University, Shanghai, 200433, China
8 Department of Psychology, Faculty of Social Sciences, University of Macau, Taipa, Macau, 999078, China
9 Centre for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Macau, 999078, China
10 Center for Public Mental Health, Wenzhou Medical University, Wenzhou, 325015, China

* Corresponding Authors: Joseph T. F. Lau. Email: ; Deborah Baofeng Wang. Email:
# These authors contributed equally to this work

International Journal of Mental Health Promotion 2025, 27(10), 1423-1437. https://doi.org/10.32604/ijmhp.2025.068840

Received 07 June 2025; Accepted 22 September 2025; Issue published 31 October 2025

Abstract

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.

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Supplementary Material

Supplementary Material File

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