Emotional and behavioural problems of children with autism spectrum disorder attending mainstream schools

Abstract

Emotional and behavioural problems occur more commonly in children with Autism Spectrum Disorder (ASD) compared to other children. Few studies have focused on these problems in children with ASD attending mainstream schools. We assessed via parent report the emotional and behavioural problems in 160 children aged 4-17 years with ASD attending mainstream schools and investigated differences between the primary and secondary aged children. Children with ASD had higher levels of problems across all domains of the Strengths and Difficulties Questionnaire (SDQ) compared to UK norms. Within the ASD sample, SDQ scores were associated with male sex, living in a household with more children, more severe autism symptoms and fewer adaptive skills, and higher levels of family socio-economic risk. No robust primary-secondary school differences were found. Implications for future research and the support of children with ASD in mainstream school settings are discussed.

Introduction

Children and young people with Autism Spectrum Disorder (ASD), a life-long neurodevelopmental condition affecting approximately 1.2% of the population (Diallo et al. 2018), have an increased risk of developing mental health problems including anxiety and depression (Hepburn et al. 2014, Ratcliffe et al. 2015, Simonoff et al. 2008, Weiss 2014). Population-based studies suggest that up to 40-50% of children with ASD have emotional and behavioural problems at a level of clinical concern (Totsika et al. 2011). In addition, approximately 41% of young people with ASD may meet the criteria for two or more mental health disorders (Simonoff et al. 2008).

School is an important context for children and young people because it is one of the main environments in which they spend their formative years and it provides a ready context for well-being interventions (DfE, 2016, 2017, Fazel et al. 2014, NICE 2009, Paulus et al. 2016). In particular, mental health problems are associated with poorer academic attainment, poorer attendance, and poorer social outcomes in school for young people in general (Hjorth et al. 2016). Similar associations with academic attainment and other outcomes such as an impact on wellbeing and relationships, have also been reported for young people with ASD who also have mental health problems (Danker et al. 2016, Hebron and Humphrey 2014). However, most research on the emotional and behavioural problems of children with ASD has focused on either clinical samples (Green et al. 2000, Mandell et al. 2005, Bryson et al. 2008), population-based studies of ASD (e.g. Simonoff et al. 2008), or general population mental health surveys (Totsika et al. 2011). There are few studies on the mental health of school-based populations of children with ASD.

There is a small number of research studies on the emotional and behavioural problems of children with ASD in special school settings. A UK study of children with ASD and intellectual disability identified high levels of emotional and behavioural difficulties with only a minority accessing mental health services (Salomone et al. 2014). According to teachers of pupils in a primary special school population in Singapore, pupils with ASD had an elevated level of behaviour problems including disruptive/antisocial behaviour, self-absorption, communication disturbance, anxiety and social relating in comparison to a group with multiple disabilities (Poon 2012). High rates of anxiety across the range of ability were reported by parents of 6-18-year olds with ASD also attending special schools in Singapore (Magiati et al., 2016).

Children and young people with ASD are also increasingly included within mainstream school provision both in the UK (Humphrey and Lewis 2008, Osborne and Reed 2011, Dillon et al. 2016) and internationally (Lindsay et al. 2013 and Saggers 2015), and difficulties have been highlighted for young people with ASD in this setting. For example, parents and teachers reported significant problems with social skills (cooperation, assertion, self-control), and more problem behaviours (hyperactivity and internalizing) in a mainstream and pre-school group of children with High Functioning Autism or Autism Spectrum Disorder aged 4 to 10 years (Macintosh and Dissanayake 2006). Ashburner et al. (2010) found that children aged 6-10 years, diagnosed with ASD were rated by their teachers as exhibiting significantly higher levels of behavioural and emotional difficulties than their typically developing peers. These difficulties included emotional lability and regulation (53%), oppositional behaviour (39%) and aggressive behaviour (14%). Fifty four percent of students with ASD were also underachieving academically compared to 8% of typically developing peers (Ashburner et al. 2010).

Teacher perceptions of difficulties in the secondary school setting suggest that behavioural and emotional problems for young people with ASD continue into adolescence. For example, Hebron and Humphrey (2014) profiled the mental health of adolescents aged 11-17 in mainstream school comparing students with ASD to a group with Special Educational Needs (SEN- dyslexia) and a group with none (non-SEN). The ASD group were found to have significantly greater anxiety, depression and anger, and lower self-concept than the non-SEN group; and significantly greater anxiety and anger than the dyslexia group. Qualitative interviews identified difficulties with social relationships, poor understanding of ASD, and lack of predictability and routine as contributory factors to poor mental health.

Whilst the emotional and behavioural difficulties associated with having an ASD diagnosis are well known, there has been less focus on the challenges facing this group of children and young people in mainstream schools and investigating the factors associated with these difficulties. Studies have explored the experiences of students with ASD in mainstream settings (e.g. Danker et al. 2016, Humphrey and Lewis 2008, Saggers 2015) and educators’ views on inclusion (e.g. Ashburner et al. 2010, Aysina et al. 2020, Teixeira De Matos and Morgado 2016, Lindsay et al. 2014) however there has been less focus on the views of parents of this group and their emotional and behavioural problems in school, and how these might differ in primary and secondary settings. In the current study, we examined parental reports of emotional and behavioural problems experienced by young people with ASD attending mainstream primary and secondary school settings. We also examined correlates of emotional and behavioural problems in young people with ASD in mainstream schools.

Method

Participants

One hundred and sixty parental primary carers between 23 and 55 years of age (mean age 41.99 years, SD = 7.20) participated in the research. One hundred and forty-six were mothers, 10 fathers, 1 grandmother, 1 foster carer, and 2 adoptive parents. One hundred and thirty-three (83.1%) were married or living with a partner and 27 (16.9%) were divorced, separated, single, widowed or not living with a partner. The total number of children living in the family home ranged from one to five (mode = 2). In terms of ethnicity, 156 (97.5%) described themselves as White (British/Irish/Other). Seventy-four (46.5%) of the primary carers had a university degree. One hundred and two (63.7%) primary carers had a paid job outside of the family home (1 did not provide information). Sixty-nine (45.1%) primary carers reported a family income at the time of the research of above £35,000 (approximately 50–55,000 US Dollars at the time of the research) and 84 (54.9%) reported an income below this level (7 primary carers (4.4%) did not provide any income information).

The children with an ASD were 136 boys and 24 girls. Their ages ranged between five and 17 years with a mean age of 10.46 years (SD = 2.73). Based on parental report, 52 children had received a diagnosis from a clinical psychologist, 62 had been diagnosed by a paediatrician, 30 children had received their diagnosis through a multidisciplinary team, 12 children had been diagnosed by a psychiatrist, and for 10 children information on who provided the diagnosis was not given. Thirty-one children attended mainstream school with no reported additional support, 114 attended mainstream school with some support, and 15 children attended a specialist autism unit in mainstream school. One hundred and four children (65%) were in primary school and 55 (34.4%) were in secondary school (for 1 child school information was missing).

Measures

A questionnaire captured demographic information about the parents and their children (see Participants). A family socio-economic risk index was created based on four of the demographic variables: whether families were headed by single parents, highest level of qualification (degree vs. no degree), employment status (households with no adult in paid employment vs. at least one adult in paid employment), and the level of household income (high, > £35,000 or low < £34,999). Each of these putative socio-economic risks was coded as present or absent and scored 0 or 1. These scores were summed to create a risk index with scores ranging from 0 to 4. Thirty-nine families had none of the four socioeconomic risks, 33 had one, 50 had two, 30 had three, and 7 had four (data were missing for one family).

Children’s emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ; Goodman 1997). The SDQ is a well-validated instrument proven to be effective in identifying clinically significant levels of behavioural and emotional problems in children (Goodman 1997). The SDQ was completed by primary caregivers. The 25-item questionnaire has five subscales and measures four problem domains: emotional symptoms, conduct problems, hyperactivity, and peer problems; as well as prosocial behaviour. Respondents rate the statements about their child as not true, somewhat true, or certainly true, based on the child’s behaviour over the past 6 months. Example items from each subscale include: ‘Often unhappy, down-hearted or tearful’ (emotional symptoms); ‘Generally obedient, usually does what adults request’ (conduct problems); ‘Restless, overactive, cannot stay still for long’ (hyperactivity); ‘Rather solitary, tends to play alone’ (peer problems); ‘Helpful if someone is hurt, upset or feeling ill’ (prosocial behaviour). Each item is scored 0–2, with subscale scores across five items ranging from 0 to 10. Higher scores indicate higher levels of problems (with the exception of the Prosocial behaviour scale). The sum of the four problem domains generates a ‘total difficulties’ score. Scale scores can be pro-rated if at least three items in each subscale are completed. Screening cut-offs for the SDQ for total and sub-scale scores are available from a nationally representative community sample of 10,438 UK five to 15-year-olds (Meltzer et al. 2003). The SDQ has been demonstrated to be effective at identifying clinically significant levels of behavioural difficulties in children (Goodman 1997, 2001) and good levels of reliability have been reported for its use in research with children with autism (e.g. Iizuka et al. 2010). The internal consistency (Cronbach’s alpha coefficient) for the SDQ scores of the present sample were: emotion = .755, conduct = .755, hyperactivity = .738, peer problems = .486, prosocial = .734 and total difficulties = .683.

The Social Communication Questionnaire (SCQ; Rutter Bailey et al., 2003) was used to measure the extent of the child’s autism symptoms. The SCQ is an autism-screening scale completed by a carer and the version used in the present research was based on international diagnostic criteria at the time of the study (DSM-IV: American Psychiatric Association 2000; ICD-10: World Health Organization 2009). The Current Form of the scale was used for the present research, assessing the child’s behaviour and severity of autism symptoms over the preceding 3-month period. The SCQ consists of 40 items, and participants answer yes/no to statements such as: ‘Is she/he now able to talk using short phrases or sentences?’ and ‘Does she/he play any pretend or make-believe games?’ A cut-off score of 15 out of a possible 39 (Item 1 does not have a scoring value as it documents whether or not the child can speak and dictates which of the remaining items to answer) is recommended as an indicator of a possible ASD (Rutter Bailey et al., 2003). The mean score in the present study was 20.85 (SD = 7.17), with 133 children (81%) scoring above the recommended cut-off. In the present study, internal consistency for the SCQ total score (Kuder–Richardson coefficient) was .83.

The Vineland Adaptive Behavior Scales-2nd Edition (VABS II; Sparrow et al. 2005) was used to measure the level of the child’s adaptive functioning. The VABS II is administered as a semi-structured interview and was conducted with the child’s primary caregiver over the telephone. The VABS II is composed of items arranged in developmental sequence that measure adaptive behaviours across four domains: socialisation, communication, daily living skills, and motor skills (the motor skills domain is only administered to children below the age of 7). An overall adaptive behaviour composite standard score was used in the analyses.

Procedure

Following receipt of ethical approval for the research from Bangor University, 1000 invitations were given to a national autism charity to distribute amongst families who had previously attended one of their introductory support programmes as a part of a larger autism family research study (Petalas et al. 2012). Three hundred and five families, who met the inclusion criteria (presence of a child with autism between the ages of five to 17 years, and a primary caregiver present in the home), expressed an interest in the research by returning the invitation with their personal contact details. Questionnaire packs were sent out to the families, and a member of the research team telephoned the families for an interview with the primary caregiver. Of the 305 families who were mailed questionnaires, responses were received from 215. If questionnaires were not returned within two weeks of being sent out, a personally addressed reminder letter was mailed to the home. The current study focused on the 160 children with ASD who attended mainstream schools.

Data analysis

In addition to scores on each SDQ scale, levels of emotional and behavioural problems within the sample of children and adolescents with ASD were categorised as ‘typical’/‘borderline’ or ‘abnormal’ according to the age-and gender-appropriate UK norms, (Meltzer et al. 2003). One sample t-tests were used to compare the present data to norms and independent samples t-tests to compare the primary and secondary age children with ASD. Binomial tests were used to compare the proportion of children with autism in the SDQ clinical range with population norms, and chi square tests to compare the primary and secondary age children in terms of the proportion with scores in the clinical range. An alpha level of .05 was used to determine statistical significance. This was not adjusted for multiple testing to avoid inflating Type 2 error rates.

A multiple linear regression analysis was used to examine associations between demographic, socio-economic factors and SDQ scores. The assumptions of regression in relation to the collinearity and normal distribution of residuals were examined using the Durbin-Warson test statistic, VIF (Variance Inflation Factor) and tolerance statistics and plots of residuals. All of the indicators were within acceptable limits for all models. Predictor variables were entered together and were the gender of child, SCQ total score, VABS composite standard score, primary or secondary school attendance, whether the child received additional support in school, number of children in the household, and the Family Socio-economic Risk Index score. Demographic factors not included in the regression models were the age of the primary caregiver, carer ethnicity (numbers of non-white were too small), and the gender of the primary carer (numbers of males too small).

Results

Comparison with norms, and primary-secondary school differences

Both the primary and secondary school children with ASD had significantly higher scores (lower for prosocial behaviour) on all SDQ scales in comparison to UK norms (all p <.001) (see Table 1). Cohen’s d was estimated using a standard formula (dividing the difference between the group means by the pooled standardised deviation). Differences for the primary and secondary ASD groups compared to norms were all associated with large to very large effect sizes. Within the ASD sample, there were no primary-secondary school differences except for Hyperactivity where mean scores were marginally higher in primary age children (p= .050) and associated effect sizes were all small (see Table 1).

Table 1.

Mean SDQ scores for primary and secondary age children with ASD and comparisons with UK norms.

SDQ domain	Primary age ASD Mean (SD)	Primary age Norm Mean (SD)	t	d	Secondary age ASD Mean (SD)	Secondary age Norm Mean (SD)	t	d	t test secondary ASD vs primary ASD	d
Emotional	5.18 (2.71)	1.9 (2.0)	12.12	1.38**	5.8 (2.62)	1.9 (2.0)	11.038	1.67**	−1.629	0.23
Conduct	3.66 (2.24)	1.6 (1.7)	9.373	1.04**	3.67 (2.26)	1.5 (1.7)	7.126	1.08**	.000	0.004
Hyperactivity	7.6 (2.35)	3.6 (2.7)	17.338	1.58**	6.82 (2.59)	3.2 (2.6)	10.361	1.39**	1.976	0.031*
Peer	5.44 (1.99)	1.4 (1.7)	20.668	2.18**	5.94 (2.20)	1.5 (1.7)	15.001	2.26**	−1.838	0.024
Pro Social	3.48 (2.35)	8.6 (1.6)	−22.35	2.55**	3.92 (2.40)	8.6 (1.6)	−14.471	2.29**	.384	0.18
Total	21.88 (6.30)	8.6 (5.7)	21.503	2.21**	22.24 (6.59)	8.2 (5.8)	15.793	2.26**	-.529	0.06

^*Significant at p = 0.05.

^**Significant at p < 0.001.

Binomial tests indicated that the proportion of children and young people with ASD scoring above the clinical cut-offs on all subscales of the SDQ was higher for every SDQ domain when compared with normative data. This was true for both the primary and secondary age groups (see Table 2). Comparing the proportions for primary and secondary ASD groups in the clinical range, chi-square tests showed no significant group differences for any of the SDQ scales (see Table 2).

Table 2.

Proportions of children with ASD exceeding SDQ clinical cut-off scores compared with UK norms.

Parent	Primary age Normative sample Frequency Norm %	Primary age ASD proportion in abnormal range %	Primary age ASD vs Norms p value	Secondary age Normative sample Frequency Norm %	Secondary age ASD proportion in abnormal range %	Secondary age ASD vs Norms p value	Primary age ASD vs Secondary age ASD p value
Emotional	10.8	61.5	<.001*	12.2	63.6	<.001*	.171
Conduct	13.1	46.2	<.001*	12.2	50.9	<.001*	.980
Hyperactivity	16.1	68.3	<.001*	12.8	58.2	<.001*	.057
Peer	11.0	84.6	<.001*	12.7	89.1	<.001*	.148
Pro Social	2.0	71.2	<.001*	2.7	63.6	<.001*	.268
Total	9.9	79.8	<.001*	9.7	80.0	<.001*	.740

^*Significant at p > 0.1.

Correlates of emotional and behavioural problems in children and young people with ASD in mainstream schools

The results of the regression analyses are displayed in Table 3. Child gender was associated only with SDQ hyperactivity scores (p = .018) with boys having higher hyperactivity scores than girls. More severe ASD symptoms were associated with higher SDQ emotional problems (p = .024), and total difficulties (p = .009) scores and lower prosocial behaviour (p = .009) scores. A higher level of adaptive behaviour was associated with higher prosocial behaviour scores (p < .001), and lower levels of adaptive behaviour were marginally associated with increased emotional problems (p = .054), and with hyperactivity (p=.001), peer problems (p= .045), and total difficulties (p = .001) scores. Whether the child was receiving additional support in school was associated with lower scores for SDQ emotional problems (p = .013), and lower levels of conduct problems (p = .004). Children with ASD in families exposed to more socio-economic risks had higher emotional problems (p = .047), conduct problems (p = .039), peer problems (p = .010), and SDQ total difficulties (p = .001) scores.

Table 3.

Regression analysis of SDQ scores for children with ASD attending mainstream schools.

Predictor	SDQ Emotionala		SDQ Conductb		SDQ Hyperactivityc		SDQ Peer Problemsd		SDQ Prosociale		SDQ Total f
	β	p	β	p	β	p	β	p	β	p	β	p
Gender of Child with autism	.115	.174	.069	.428	-.206	.018**	-.029	.783	-.021	.799	-.017	.824
SCQ Total	.227	.024**	.169	.101	.073	.477	.160	.119	-.262	.009*	.241	.009*
VABS Adaptive Behaviour Composite	-.183	.054	-.094	.337	-.317	.001*	-.196	.045**	.340	.000*	-.304	.001*
Primary/Secondary	.045	.602	.049	.576	-.155	.079	.104	.237	.153	.074	.012	.882
Support in school	−2.13	.013**	-.252	.004*	.046	.590	-.113	.191	.087	.297	-.200	.010*
No of children in household	.026	.756	.162	.065	-.028	.746	-.029	.737	.104	.221	.046	.548
Family Socioeconomic risk index	.180	.047**	.193	.039**	.123	.181	.241	.010*	.048	.589	.276	.001*

^*Significant at p > 0.1.

^**Significant at p > 0.5.

^a R = .492, R² = .244, F(7, 119) = 5.121, p<.001.

^b R = .446, R² = .199, F(7, 119) = 3.980, p<.001.

^c R = .455, R² = .207, F(7, 119) = 4.187, p<.001.

^d R = .456, R² = .208, F(7, 119) = 4.202, p<.001.

^e R = .500, R² = .250, F(7, 119) = 5.328, p<.001.

^f R = .614, R² = .377, F(7, 119)= 9.688, p<.001.

Discussion

Results in this study showed elevated rates of emotional and behavioural problems and lower prosocial behaviours, (measured by the SDQ) for children with ASD in both primary and secondary settings, when compared to UK norms. These results are in line with existing research highlighting the additional problems experienced alongside an ASD diagnosis. Apart from marginally higher hyperactivity scores in the primary aged group, no differences were found between the primary and secondary ASD groups. Results from the regression analysis showed elevated rates of emotional and behavioural problems in children and young people with ASD (measured by the SDQ) were associated with gender (being male), higher scores on the SCQ (more autism symptoms), a lower score on the VABS (lower adaptive skills), and having a high score on the family Socio Economic Risk Index. A lower level of emotional and behavioural problems (on the emotion, conduct, peer problems and total scores scales) and higher prosocial behaviour was associated with receiving additional support in school. There was no association found between level of behavioural and emotional difficulties and the number of children in the household, or whether the child with ASD was in primary or secondary school.

In this study an association with being male and having increased emotional and behavioural difficulties was identified. This is in line with other studies such as Gotham et al. (2015) and Posserud et al. (2018) who found higher rates of comorbidity and impairment in boys with ASD, although similar gender differences are not consistently identified in the literature. Higher levels of emotional symptoms and peer problems have been found in children with ASD of both sexes (Horiuchi et al. 2014), and girls with ASD have been found to have a greater increase in the levels of anxiety and depressions symptoms (Gotham et al. 2015, Solomon et al. 2012) and conduct problems with age. Kozlowski et al. (2012) found no gender differences in the occurrence of challenging behaviour amongst children with ASD. Differences may be explained by a genuine difference in occurrence rates, a gender bias in the assessment tools (Duvekot et al. 2016) or the acknowledged under diagnosis of ASD in girls which has been calculated as male to female 2-3:1 (Lai et al. 2015) and 3:1 (Loomes et al. 2017), although girls and boys are similarly impaired by ASD (Solomon et al. 2012). Differences in presentation may mean that boys who display emotional and behavioural problems are more likely to be diagnosed with ASD and there is a risk that girls with ASD who do not display emotional and behavioural problems may be overlooked for diagnosis or intervention (Solomon et al. 2012). Considering the smaller number of girls in this study, it is possible additional effects may have been observed in a sample with more females.

Higher levels of behavioural and emotional problems were associated with ASD severity (Andersen et al. 2017, Horiuchi et al. 2014, Posserud et al. 2018). Lower levels of adaptive skills and increased levels of ASD symptomatology (reflected in SCQ scores) would be expected to bring challenges especially in the school environment where the demands of social interaction and the school routine are high (Dillon et al. 2016, Humphrey and Lewis 2008, Simonoff et al. 2013). The parents in this study reported that their children had fewer difficulties where additional support was provided. One possible explanation for this is that the provision of extra support mitigates difficulties experienced. It is not possible to infer a causal link from these data and more research is needed to explore this.

Whilst there is an established link between socio-economic status and mental health difficulties in children in the general population (Mowat 2019, Reiss 2013), a complex interplay of factors means that the precise effect of socio-economic disadvantage on the mental health difficulties of children with ASD is hard to determine. Family poverty is a risk factor for externalising problems in children with ASD (Midouhas et al. 2013) and emotional problems in children and young people with ASD are predicted by family-based deprivation and lower parental social class (Simonoff et al. 2013). Whilst poverty may not be a risk factor for ASD, it has been associated with higher levels of emotional problems in children with ASD and ADHD (Flouri et al. 2015) and ASD alone (Simonoff et al. 2013) and may exacerbate problems for these children due to the accumulation of risk they experience. The picture is further confused as means of measuring socio-economic disadvantage vary across studies and more studies are needed to identify any ASD specific links to poverty and disadvantage.

We found no significant differences in levels of emotional and behavioural problems between children attending primary versus secondary schools, which may be in line with studies reporting that ASD core symptoms persist throughout the lifespan (Matson and Horovitz 2010, Munir et al. 2015). On the other hand, detecting changes or differences between these groups and may depend on the measurement and focus. Simonoff et al. (2013) found psychiatric problems to be persistent and domain-specific (conduct, emotion and peer problems) from childhood to adolescence when ASD specific cut offs on the SDQ were applied. However, Horiuchi et al. (2014) observed significant increases in emotional and behavioural difficulties but with differences according to characteristics: both genders saw increased emotional symptoms and peer problems, and girls saw more conduct problems with increased with age. In an additional exploratory analysis the primary school ASD group did score significantly higher on the VABS (indicating higher adaptive functioning), primary M = 71.1724, secondary M = 67.2667, mean difference 3.90575 [CI .29585, 7.51564], t (130) = 2.141, p = .034. It is possible that by the time of reaching secondary school, those with lower levels of functioning have moved into special schools. There is clearly need for more longitudinal research to investigate what happens as these children progress through school.

Limitations

Several factors limit the conclusions that can be drawn from these findings. In this study, behavioural and emotional problems were reported by parents, the majority of whom (95.6%) were female. Relying on only a single informant and a largely female perspective excludes potentially valuable information from male carers and other independent sources. Future research should incorporate multiple informants to address this. Parental mental health was not assessed but may well have a bearing on parent reports. Parents of children with ASD have been found to have higher levels of emotional disorder themselves (Rauf et al. 2014, Simonoff et al. 2013, Yorke et al. 2018) and this may lead to bias in their reporting. In addition, although the SDQ is used widely with children and adolescents (Meltzer et al. 2003) and increasingly with those with an ASD (Findon et al., 2016, Jones and Frederickson 2010, Osborne and Reed 2011, Simonoff et al. 2013), it may not capture other aspects of ASD experience that may be relevant (e.g. sleep difficulties), and requires further research. Finally, the design was cross-sectional and so it is not possible to infer causality.

Practice implications

The findings from this research demonstrate that difficulties are apparent for a significant proportion of children with ASD taught within mainstream schools, and so there is a need to offer them mental health and well-being support in the school context. Systematic reviews of interventions for ASD have found evidence to support the use of multi-component targeted interventions focused on social skills and behaviour problems (Bond et al. (2016) and psychosocial interventions for autism (Seida et al. 2009). The findings in this research also suggest the need for schools to assess and review the particular needs of this group at a more individualised level, in addition to whole school approaches, to take account of variations in presentation with age, gender, level of ASD and level of functioning and to tailor interventions accordingly with a particular focus on managing emotions, conduct and peer problems.

Conflict of interest

No potential conflict of interest was reported by the authors

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.