Predicting Relationship Between Anxiety and School Avoidance in Children and Adolescents with and Without Learning Disabilities in Educational Setups in Pakistan: A Comparative Study

This study aimed to investigate anxiety and school avoidance in individuals with and without learning disabilities. The study employed quantitative survey-based approach, with comparative research design. N= 160 participants between 8 till 18 years were selected via Purposive sampling technique. Screen for Child Anxiety Related Disorders (Birmaher et al., 1999) was administered to measure anxiety and school avoidance and Learning Disabilities Checklist (National Centre for Learning Disabilities, 2007) was used to assess learning disabilities in participants. Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 22. Results were analyzed using descriptive and inferential statistics. Correlation and regression analysis were done to study the relationship and level of variance between the variables. Results indicated significant differences on the variable of anxiety (t=-3.95, df =140.71, p <.01) and school avoidance (t=-3.80, df =131.38, p <.01) in both groups. A significant relationship (p<.01) between anxiety and school avoidance was also reported in learning disabled groups; providing a valuable insight regarding increased vulnerability of internalizing disorders particularly related to anxiety in younger population in Pakistan.


Introduction
Anxiety is considered as a heightened emotional response to triggering events.It is said to be the most prevailing category of mental disorder with in young population and the sixth leading cause of disability globally (Baxter et al., 2014).A report by the United Nations, 2011 stated the prevalence of mental and emotional disabilities to be approximately 10 % of the total world population.Among this disabled population, 80 percent belong to developing countries including Pakistan.Literature has further linked these disorders predominantly anxiety to be more prevalent in children and adolescents (Rockhill et al., 2010) and if these concerns remain unaddressed for long they may adversely affect their academics and day to day functioning (Kleine, 2009;Mardomingo, 1994).The relationship between clinical anxiety and academic underachievement has been investigated among young Mexican children.It was noted that the student who scored low on the study index manifested elevated level of anxiety (Hernández et al., 2008).
Young people with academic underachievement and learning concerns unfortunately become a subject to maltreatment and discriminatory attitude by the people around.They are often rejected by their class mates making them more vulnerable of having mental and emotional concerns such as insecurity, low selfconcept and anxiety etc. (Jadue, 2001).Furthermore, it impacts their academic functioning, and develops fear of going to school which is often termed as school avoidance, school refusal or school phobia.(The Dawn News, 2013).
The significant relationship between emotional disorders like anxiety and school avoidance in young population has been investigated in literature Kearney and Albano (2004) suggested that the most common disorders that arise in children, in addition to school refusal, are anxiety disorders including specific phobias, separation anxiety, panic disorder, post-traumatic stress disorder, adjustment disorder, and depressive disorders.Egger et al. (2003) elaborate psychological dysfunctions to be associated with school refusal and absenteeism.They found that in addition to schooling and socio demographic factors, mental illnesses are one of the significant causes behind school refusal.The existing literature provide information regarding the effects of anxiety and related emotional disorders and their impact on student's academic motivation.However, these factors have not been much investigated in students with disabilities and learning concerns particularly in Pakistan, therefore, the main objective of this study was to find out the possible relationship between school avoidance/refusal and anxiety disorder among school going children and adolescents with learning disabilities in our local setup.
Pakistan is said to be the fifth densely populated country (United Nations, 2023) with the literacy rate of 58.9% (International Federation of Red Cross & Red Crescent Societies, IFRC, 2023).According to the available statistics more than 1.8 million individuals are affected by learning disabilities in Pakistan (The Express Tribune, 2013).With regard to the mental health status around 50 million people are suffering from common mental disorders such as anxiety and depression.Among these approximately 15 to 35 million are adults along with 20 million children.Additionally, research reports 26.7% children to be displaying school avoidant behavior (Mahmood, 2018).These statistics provide compelling evidence to conduct the current study and to identify the risk factors or any possible relationship that anxiety may have with school refusal behavior in students with learning disabilities.The rising rate of anxiety in Pakistan along with a low literacy rate may suggest a link between the two.It is likely that rising anxiety may interfere with a positive experience and student's attitude towards academics.
Keeping these facts in perspective work needs to be done to investigate the factors and design strategies to address young people's difficulties in order to maximize their potentials.There is a need to address the gap knowledge regarding factors like emotional disorders such as anxiety and school avoidance/refusal among children and adolescents with learning and other disabilities.Moreover, there is a great need to work on the life of children with cognitive decline and learning concerns efforts should be made to the improve learning conditions for them and provide them with necessary facilitation in case of any psychological or emotional concerns.
Unfortunately, in Pakistani culture, psychological concerns are not considered seriously.They are often ignored and remain unnoticed which significantly impact individuals functioning in important domains of life.Education is the area that has been ignored significantly in our country.Emotional or psychological illness in young people directly impact young people's academic functioning and readiness for school.Children and adolescents who refuse to go to school and express physiological complain such as pain, lethargy, etc. is commonly taken as malingering and truancy by the significant ones.They are dealt with strict disciplinary measures which further cause impairment and complicate the issues.In order to address these factors, this study was executed.This research provides empirical evidence to undermine the prevailing notions in the society, so that the real causes of such behavior in children may be identified.When these causes are clearly identified, a better solution could be generated.

Literature Review
In a typically developing individual the manifestation of anxiety is a part of usual routine.It is a mechanism of dealing with challenging situation so there appears to be little concern if one experiences discomfort due to anxiety but ends up in successfully fulfilling tasks at hand (Pine et al., 2009).Anxiety can be described as pathological when it causes affective deterioration leading to insecurity, fear of negative evaluation and use of avoiding tactics (Godbout, 2019).In case of young individuals, differentiating anxiety as pathological or a part of normal developmental process becomes challenging.Children manifest anxieties and fearfulness regularly in their daily life; what distinguishes normal anxious response from pathological is how a person adapts or responds to the environment triggers (Feriante & Bernstein, 2020).
Referring to the Pakistani scenario, despite of the scarcity of research done in this area, the available sources suggest internalizing disorders such as anxiety and depression to be mostly prevalent in 50% urban population (Ali et al., 2002;Niaz et al., 2004) which is comparatively higher than other underdeveloped countries worldwide.While exploring the link between anxiety and school related fears, Mahmood (2018) in a research reported 26.7% children to be displaying associated school avoidant behavior.This lack of motivation to attend school appeared to be linked with several causes including anxiety.Kearney et al. (2010) also investigated the relationship between anxiety and school refusal/ avoidance behavior in younger population between 5 till 17 years.They found positive correlation between school avoidance and anxiety related physiological symptoms such as headaches, stomachaches, nausea, diarrhea etc.It was further indicated that these symptoms were mostly evident in children before going to school and subsided while staying home or avoiding school (Anxiety and Depression Association of America, 2019).Moreover, the schools also reported frequent referrals to the school sick bays or clinics.
Anxiety and other emotional disorders significantly inhibit socio-emotional and cognitive development in young people but the case worsens when it cooccurs with learning disabilities.The effects of the co-occurrence of anxiety and learning disabilities have been studied extensively (Bailey & Andrews, 2003).The expression of these concerns at the same time often makes it challenging for the identification, treatment and management of the symptoms which in some cases even left unaddressed.(Matschke, 2023).According to a metanalytical analysis, about 70% of students with learning disabilities often report high levels of anxiety and related concerns (Nelson & Harwood, 2011).In another study, 20 % of individuals with learning problems reported elevated levels of anxiety compared to 10% of the non-leaning disabled counterparts (Wilson et al., 2009).
Uninhibited anxiety often seems to exhibit secondary concerns in the form of reduced activity level and readiness towards task performance.This demotivation and lack of readiness towards academic performance along with learning concerns becomes a serious matter which needs to be investigated.For the purpose of highlighting and investigating the relationship between these factors, the following hypotheses were framed: Hypotheses 1.There will be significant difference between the levels of anxiety in young people with and without learning disabilities.
2. There will be significant difference between the scores of the variable of school avoidance in young people with and without learning disabilities.
3. There will be a significant correlation between anxiety and school avoidance in children and adolescents with learning disabilities.

Research Design
The study employs Quantitative Survey based approach, with comparative research design.The data was collected via purposive sampling technique utilizing Structured Self -Report Questionnaires.

Participants
For the study, Purposive sampling technique was used to select (N= 160) individuals age between 8 to 18 years.The mean age was 12.21.Participants were approached from different mainstream, inclusive and special schools located in Karachi, Pakistan.

Inclusion Criteria
• Individuals ranging from 8 to 18 years of age.
• Individuals identified with learning disabilities.

Exclusion Criteria
• Individuals with physical disabilities.
• Individuals below age 8 or over age 18.

Measures
Screen for Child Anxiety Related Emotional Disorders-Child (Birmaher et al., 1999).SCARED-C was used to assess symptoms of anxiety in children.This scale is available in two versions, the parent and child.For the present study child version was used.This 41 items scale assesses symptoms of DSM-IV classification of anxiety disorders including generalized anxiety, separation anxiety, social anxiety, panic or somatic symptoms and additional variable school avoidance is also assessed in this scale.The SCARED demonstrated good internal consistency ranging from .74 to .89 and is available in public domain.Learning Disabilities Checklist (National Centre for Learning Disabilities, Inc. 2007) Learning disabilities checklist (LDC) was administered to gauge learning disabilities in participants.LDC constitutes 91 items designed to identify learning disabilities in 7 domains, these include attention, language, reading, written language, math, gross and fine motor skills, and social emotional skills.The scale has satisfactory alpha reliability index of 0.9 (NCLD, Inc. 2007).The scale was validated according to local norms by Ashraf and Najam (2014).
The demographic information including participant's age, gender, number of siblings, birth order etc. were assessed using a demographics questionnaire developed by the researcher.

Procedure
The study initiated by providing the letter of consent mentioning the purpose of the study along with the scale description to the concerned authorities of randomly selected main stream, inclusive and special educational setups of Karachi, Pakistan.Participants with learning disabilities were carefully selected following the evaluation by certified clinical psychologist.In case of mainstream schools, the resource teachers facilitated in identifying the students with learning concerns.After the identification of individuals with learning disabilities, Learning Disabilities Checklist was administered to satisfy the inclusion criteria.Participants who fulfilled the criteria were selected for the study.
The tools were used in the study after seeking permission from the authors.Thereafter, they were administered with the facilitation of resource teachers and trained staff after clarifying any doubts and queries.Following a rapport building session, the scales were administered on one on bases in case of young participants and group administration was done with the older ones.Learning disabilities check list was administered first.After five minutes break, the scale to assess the symptoms of anxiety and school avoidance was administered.The obtained data was scored according to the set standards and further analyzed via SPSS software.

Ethical Considerations
The study was pursued keeping in mind all the relevant ethical considerations.The scales were used after seeking permission from the authors.The subjects were informed about their voluntary participation and the right to withdraw from the study at any time.In the case of young participants, their teachers were taken into a loop.They were also briefed about the confidentiality of the information given and concerns regarding data protection, anonymity and related matters were carefully addressed.

Statistical Procedures and Data Analysis
Statistical Package for Social Sciences, version 22 (SPSS V.22) was used to investigate the hypotheses.Results were analyzed using descriptive and inferential statistics.T-test was calculated to find differences in the levels of anxiety and school avoidance in participants with and without learning disabilities.Pearson's product moment coefficient of correlation ('r') was calculated to observe possible relationship between the two variables anxiety and school avoidance in children and adolescents with learning disabilities.Furthermore, regression analysis was done to find out the effective relationship between the two variables anxiety and school avoidance.

Data Analysis
The obtained data was organized and analyzed via descriptive and inferential statistics with the help of the statistical package, SPSS.The hypotheses were tested and the significant differences between the scores of the two groups on the variables were examined.

Result Reliability Analysis
Table 2 indicates the Cronbach alpha reliability coefficient of scales used in the study.The reliability score of the Learning Disability Checklist, which consists of 92 items fall in the high range, i.e. .98 and the Screen for Children Anxiety Related Emotional Disorders consisting of 41 items also fall in the high range i.e., .87.

Assumption 1
According to the first assumption the group differences on the level of anxiety was investigated.Results indicated that individuals with learning disabilities manifested raised levels of anxiety compared to the ones without learning disabilities.Table 3 explains the differences in the level of anxiety between the nonlearning disabled and learning-disabled groups.The mean score of the learningdisabled group was significantly higher (M= 34.90,SD= 13.86) than the nonlearning-disabled group (M= 27.43,SD= 9.60).Furthermore, the t-test indicates difference in the level of Anxiety in Learning and Non-Learning-Disabled groups (t= -3.95, df= 140.71, p˂ .01).The results highlighted significant difference between Learning and Non-Learning-disabled individuals on the level of Anxiety.Furthermore, the results suggest moderate to high practical significance between the means scores of both the groups.

Assumption 2
Regarding the second assumption group differences on the variable of School Avoidance or school refusal were studied.The results are shown in table 3.
Table 4 explains the differences in the level of school avoidance between the non-learning disabled and learning-disabled groups.The mean score of the learning-disabled group was significantly higher (M= 2.23, SD= 1.97) than the non-learning-disabled group (M= 1.25,SD= 1.21).Furthermore, the t-test indicates difference in the level of school avoidance between Learning and Non-Learning-Disabled groups (t= -3.80, df= 131.38, p˂ .01).The results highlighted moderate to high level of statistical significance between the mean test scores of both Learning and Non-Learning-disabled individuals.

Assumption 3
The third assumption investigates possible relationship between anxiety and school avoidance in children and adolescents with learning disabilities.

Table 5
Correlation between Anxiety and School Avoidance in Children and Adolescents with Learning Disabilities.

Anxiety
.60** .000.07 .678 -.02 .912 The results of correlation indicated in Table 5, suggest significant correlations (p<.01) between anxiety and school avoidance behavior in children and adolescents with learning disabilities.Tables 6, 7 & show the impact of level of anxiety on school avoidance behavior.The R 2 value of .22 revealed that the predictors explained 22% variance in the outcome variable with F (1, 78) = 22.1, p< .05.Therefore, the findings revealed that the level of anxiety predicted school avoidance behavior (β=.47, p< .05).

Discussion
Anxiety is said to be the most prevailing mental health concern in younger population.There are several uncontrolled sources of stressors which interfere one's healthy productive living.In terms of young people school and social interaction are primary causes of stress which trigger emotional instability and psychosomatic complaints (Burns et al., 1995;Vaalamo et al., 2002).The prevalence of internalizing disorders including anxiety disorders have been increasing in younger population.It has risen from 20% to 40% in children age 10 years or younger, (Domenech et al., 2004).Previous findings have reported high risk factors for developing internalizing disorders in children and young population with learning and academic concerns.(Surén et al., 2018).Within the Pakistani scenario, this area is yet to be explored.The present study highlighted some of the factors which may impact young people's mental health and their readiness towards academic pursuit.The purpose of this study was to explore the prevalence of anxiety related emotional disorders and school avoidance in young people with learning disabilities.It was hypothesized that anxiety related emotional disorders would be highly prevalent in young people with learning disabilities compared to the ones without learning disabilities.
The findings of the study proved the assumption and appeared to be aligned with the previously available findings.Fritzsche (2020) found anxiety related somatic symptoms such as sweating, palpitation, berating difficulties in young individuals with learning disabilities.Nelson and Harwood (2010) also stressed on the possible link between anxiety and person's deteriorated functioning.Castro (2023) highlighted this with reference to individuals with learning disabilities.It was explained that young people with learning disabilities manifest symptoms of anxiety compared to the ones without learning disabilities.Loeb et al. (2018) seconds the previous findings linking learning disabilities and anxiety disorders.
Moreover, despite of the extensive work done on the investigation of anxiety disorders in learning disabled individuals, it becomes complicated with the severe and profound learning-disabled population and there is a chance of confusing symptoms of mental illnesses with learning disabilities or vice versa.In such cases due to excessive behavioral problems anxiety disorders are mostly misdiagnosed or under reported (Castro, 2023).Kakhramonovich (2022) highlighted concerns in diagnosing anxiety related disorders due to excessive behavioral disturbances in children with learning disabilities.The results as stated in table 3 corroborated the second assumption.Individuals with Learning Disabilities displayed significantly raised level of School Avoidance compared to the ones without Learning Disabilities.Similar findings were reported by Kearney et al. (1995); proposing academic concerns such as learning disabilities along with socioeconomic factors to be contributing to school avoidance behavior.Bruce and Wendy (2019) also aligned their findings concluding interpersonal and academic difficulties triggering emotional problems leading to avoidance and demotivation towards education.Significant relationship was observed between academic under achievement, avoidance behavior and school experience.The observations were based on the parent's and student's perception via self-report measures (Kearney & Albano, 2004).
In a similar study the vulnerability towards psychological concerns were significantly elevated in young individuals experiencing derogatory attitude from their school fellow.The effects appeared to hamper their self-confidence and chances of success throughout life (Kaukiainen, 2002;Mishna, 2003).School related fear and emotional concerns were manifested by students with learning disabilities (Most et al., 2000).They complained body aches, breathing issues, disturbed appetite and sleep etc. which usually subsided while staying at home (Most et al., 2000;Wiener & Schneider, 2002).
In a report generated by the Individuals with Disabilities Education Act, America (IDEA, 2016) young people with disabilities showed 1.5 times more absenteeism compared to the ones without disabilities.These included individuals with learning disabilities as well.In a country like Pakistan where the educational system faces a lot of challenges and requires substantial support and attention.The concerns of individuals with disabilities are even less addressed.With regard to individuals with academic difficulties; discipline and absenteeism is a critical concern (Aziz et al., 2020).The National Center for Education Statistics, (NCES) reported nonattendance in school to be a crucial problem in at risk learners.They appear to spend limited time in school compared to the average to high achievers (Balfanz & Byrnes, 2012).Lipscomb et al. (2017) highlighted secondary medical and psychological concerns associated to school refusal.Gottfried et al. (2017) found students with emotional disturbances to be 13% more vulnerable of avoiding school compare to the ones without any kind of emotions concerns.In case of students with learning disabilities the percentage was 7.6 times more than the normal peers.Grigorenko et al. (2019) stressed on neurodevelopmental concerns such as delayed language development, low intellectual level leading to academic underachievement and avoidant behavior.They emphasized on underlying psychological concerns including internalizing as well as externalizing disorders to be linked with poor academic achievement.

Conclusion and Recommendation
Anxiety is a standard response to stressful situations.Although the terms anxiety and stress are used interchangeably but both the terms vary.The International Dyslexia Association (IDA) defines anxiety as "A state of worry about what might be-as compared to stress, which is a reaction to what is." Every individual manifest anxiety differently and the triggers also vary accordingly.It effects 30% population in one way or the other throughout life.Individuals with learning disabilities are said to be the most vulnerable population.They experience anxiety for a variety of reasons including difficulty in performing tasks relate to problem solving, decision making and understanding and comprehending skills etc. which often obstructs other areas of their life triggering psychological or mental health concerns in the long run.
The present work has also highlighted the significant relationship between young people's academic difficulties and vulnerabilities towards psychological concerns linked to anxiety disorders.The potential attitude of individuals with learning disabilities towards academic attainment was also the subject of study.The applicability of this study with respect to Pakistani culture and educational scenario has enhanced the significance of this work as it would provide fruitful knowledge and awareness about the subject and would assist teachers, counselors and other mental health professionals in dealing with the concerns effectively and developing age appropriate treatment and remedial intervention for children and adolescents with learning disabilities.

Table 1
Demographic Characteristics of Participants

Table 2
Cronbach's Alpha for the Learning Disability Checklist and Screen for Children Anxiety Related Emotional Disorders

Table 3
Mean, Standard Deviation & Independent Sample t-test of the Level of Anxiety between NLD and LD Groups (N=160)

Table 4
Mean, Standard Deviation & Independent Sample t-test of School AvoidanceBetweenNLD and LD Groups (N=160)

Table 6
Simple Linear Regression Between Anxiety and School Avoidance (N=160)

Table 7
Simple Linear Regression Between Anxiety and School Avoidance (N=160)

Table 8
Regression Coefficients of Level of Anxiety on School Avoidance