Family factors and school refusal among children and adolescents: a systematic review and three-level meta-analysis

Background School refusal has important implications for child mental health and educational participation. Family factors have been widely studied, but quantitative synthesis of the strength of their associations remains limited. This systematic review and three-level meta-analysis examined associations between family-related risk and protective factors and school refusal among children and adolescents. Methods The review was registered with PROSPERO (CRD420261292560) and reported in accordance with PRISMA 2020. Web of Science, Scopus, PsycINFO, PubMed/MEDLINE, Embase, ERIC, and ProQuest Dissertations & Theses were searched, most recently on 18 September 2026. Eligible reports first published between 2006 and 2025 examined quantitative associations between family factors and school refusal. Direct, unadjusted effects were synthesized on the Fisher-z scale using a three-level random-effects model with study-clustered robust inference (CR2). Sensitivity analyses examined statistical inputs, inferred sample sizes, zero-cell corrections, and sampling dependence. Results Thirty-seven reports were included in the systematic review; 13 studies contributed 79 effects from 15 independent sample groups to the primary meta-analysis. Greater family risk or lower family protection was positively associated with school refusal ( r = 0.249, 95% CI [0.137, 0.354]). Heterogeneity was substantial (I 2 = 87.6%), with a model-based prediction interval of −0.149 to 0.577. The positive average persisted across study omissions and alternative sampling-correlation assumptions. Restricting the synthesis to reported correlations yielded a smaller estimate ( r = 0.171, 95% CI [0.043, 0.295]). Exploratory comparisons did not detect differences across three family domains, but limited precision left their relative strengths unresolved. Conclusion The findings support family-informed assessment within children’s emotional and school contexts. The predominantly observational evidence limits conclusions about causal and temporal direction. Longitudinal research is needed to distinguish family difficulties preceding refusal from responses associated with its persistence and recovery. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261292560 , identifier CRD420261292560.