The study, led by Molly Yeoman with colleagues including Vaso Totsika, analysed data from the UK Millennium Cohort Study, a longitudinal project following children born between 2000 and 2002 across seven waves of data collection spanning from 9 months to 17 years of age. Of the 10,228 participants with usable autism data, 160 had a parent-reported autism spectrum condition diagnosis recorded between the ages of 5 and 11. Parents also reported whether their child had been temporarily suspended or permanently excluded between ages 11 and 14, and the adolescents themselves completed the well-validated Strengths and Difficulties Questionnaire at 17, providing self-reported scores for both internalising difficulties—anxiety, depression and social withdrawal—and externalising difficulties.

The raw numbers were stark. By age 14, 21.9 percent of autistic children in the cohort had been excluded or suspended from school, compared with just 4.6 percent of their non-autistic peers. By 17, autistic adolescents reported significantly higher scores on both dimensions of mental health: internalising scores averaged 19.46 in the autism group versus 18.21 among peers, and externalising scores averaged 18.50 versus 17.34. After adjusting for a comprehensive set of confounders—sex, ethnicity, maternal age, socioeconomic deprivation, family structure, child health, prior behavioral difficulties, maternal psychological distress and parental school engagement—autism remained associated with 1.43 points higher internalising scores and 0.78 points higher externalising scores, and with more than double the odds of exclusion (an odds ratio of 2.32).

What distinguishes this study from earlier work is its statistical machinery. Simple associations between exclusion and poor mental health are notoriously difficult to interpret, because children who act out are more likely to be excluded in the first place, making the direction of cause and effect ambiguous. The research team confronted this head-on using causal mediation analysis under the counterfactual framework, employing the g-formula to estimate randomised interventional analogues of natural direct and indirect effects. This approach matters because the data contained intermediate confounders—prior externalising difficulties and maternal mental health—that are themselves influenced by autism and that also shape both exclusion and later outcomes. Simpler mediation methods would have produced biased estimates in this situation, so the g-computation procedure was essential for cleanly decomposing the total effect of autism into its direct and exclusion-mediated components.

The decomposition produced a clear and, in some ways, surprising result. For externalising symptoms, the total effect of autism was 0.69 points, of which 0.66 was a direct effect and 0.03 travelled through school exclusion—a small but statistically significant indirect pathway (95 percent confidence interval 0.004 to 0.06, p = 0.024). In other words, exclusion accounted for a modest slice of the association, estimated at roughly 4.9 percent, though the proportion itself was not statistically significant. For internalising symptoms, by contrast, the indirect effect was essentially zero (−0.0008, p = 0.936), with the entire association between autism and later anxiety and depression operating through the direct pathway. Exclusion, it seems, is a mechanism for behavioral deterioration specifically, not emotional deterioration generally.

The theoretical interpretation offered by the authors draws on the idea that schools function as protective environments, particularly for autistic young people who often depend heavily on routine, structure, predictable schedules and supportive adult supervision to regulate their behavior and emotions. When exclusion removes these scaffolds during adolescence—a developmental window already marked by heightened emotional reactivity and social pressure—the result may be a destabilising loss of exactly the supports that many autistic students rely on most. This aligns with Problem Behaviour Theory, which holds that adverse shifts in environmental context can interact with individual vulnerabilities, such as cognitive inflexibility, to elevate the risk of behavioral difficulties. Consistent with this account, research on residential mobility has shown that disrupting embedded routines and social networks predicts externalising problems more strongly than internalising ones, a pattern that mirrors the asymmetry observed here.

The findings also carry a subtler implication: exclusion does not simply reflect pre-existing behavioral problems but actively contributes to their development and escalation. Earlier studies in neurotypical populations, including work by Ford and colleagues and by Obsuth and colleagues, had already suggested that exclusion predicts later psychiatric difficulties even after accounting for prior vulnerabilities. The new study extends that logic to autistic adolescents, showing that exclusion operates as a pathway through which autism leads to externalising outcomes, rather than merely a consequence of them. A sensitivity analysis restricted to temporary suspensions only produced a similar-sized indirect effect that fell short of significance, possibly because fewer participants experienced only temporary exclusion, or because shorter removals from school are genuinely less damaging than permanent expulsion.

Why did exclusion fail to mediate internalising difficulties, when qualitative research has documented shame, low self-worth and social isolation among excluded autistic students? The authors offer several explanations. The direct pathway may reflect core features of autism itself, such as intolerance of uncertainty and sensory sensitivities, which generate emotional distress independently of school events. Measurement differences may also play a role: this study relied on adolescent self-report of internalising symptoms, whereas earlier work used parent reports, teacher reports, broader distress measures or retrospective interviews, each of which may capture different facets of emotional functioning. There is also the possibility of heterogeneity in individual experience—for some autistic adolescents facing chronic peer victimisation, which can affect a large majority of autistic students, exclusion may even offer temporary relief from bullying or the exhausting demands of camouflaging, potentially suppressing the group-level indirect effect.

The study is not without limitations, and the authors are candid about them. The autistic subsample of 160 participants is small, producing sparse data in some covariate strata and a positivity violation that the g-formula could only address through extrapolation, so the estimates warrant caution. Survey weights were not applied, limiting population representativeness, and residual confounding cannot be fully excluded despite the careful use of a directed acyclic graph to guide covariate selection. Missing data, ranging up to 34 percent across variables, were handled with multiple imputation by chained equations under a missing-at-random assumption, and the mediation models were run with 500 bootstrap replications to generate bias-corrected confidence intervals.

Even with those caveats, the practical message is pointed. Because exclusion is a modifiable environmental factor, the findings argue for preventative, autism-informed strategies that reduce reliance on exclusionary discipline altogether—better staff training, flexible policies, tailored support plans and structured reintegration programs such as low-stimulation learning hubs with one-to-one support. They also suggest that mental health outcomes in autism are not fixed by neurology alone but are shaped by social and institutional contexts that unfold over time. If a small but real share of behavioral difficulties in autistic adolescents traces back to the moment a school removes them from its community, then keeping that community intact, responsive and informed may be one of the most concrete levers available for improving autistic young people’s lives.

Subject of Research: The mediating role of school exclusion in the association between autism and adolescent internalising and externalising mental health outcomes

Article Title: School Exclusion as a Partial Mediator Between Autism and Adolescent Mental Health

Article References: School Exclusion as a Partial Mediator Between Autism and Adolescent Mental Health. (n.d.). https://doi.org/10.1007/s10803-026-07550-7

Image Credits: AI Generated

DOI: 10.1007/s10803-026-07550-7

Keywords: autism spectrum conditions, school exclusion, adolescent mental health, externalising difficulties, internalising difficulties, Millennium Cohort Study, causal mediation analysis, g-formula, Strengths and Difficulties Questionnaire, inclusive education, school discipline, UK cohort study

The research team utilized data from the Millennium Cohort Study, a sweeping nationally representative dataset originating from the United Kingdom, which has meticulously tracked children from birth through adolescence for more than two decades. Parents provided detailed reports on their children’s prosocial behaviors at ages 5, 7, and 11, capturing acts such as helping others, displaying kindness, and cooperating in social contexts. These measures were then correlated with self-reported dietary intake of fruits and vegetables when the children reached ages 14 and 17, critical periods when dietary habits tend to solidify and influence long-term health trajectories.

Lead investigator Farah Qureshi, ScD, MHS, of the Johns Hopkins Bloomberg School of Public Health, emphasizes that the prevailing narratives surrounding youth often focus on negative outcomes and risk factors, overshadowing the strengths and positive behaviors children exhibit daily. “Our analysis illuminates how proactive, caring behaviors function not only as social virtues but also as predictors of healthier lifestyle choices,” Dr. Qureshi explains. “By broadening the scope beyond isolated volunteering activities to include a spectrum of prosocial behaviors such as everyday kindness and cooperation, we highlight a vital mechanism by which children develop habits that can safeguard their well-being well into adulthood.”

The findings resonate strongly with existing psychological theories that posit social connectedness and purpose as critical determinants of health behavior. Julia K. Boehm, PhD, from Chapman University’s Department of Psychology and senior author of the study, elaborates on the biopsychosocial processes underpinning this relationship. “Prosocial individuals often experience enhanced psychological functioning, including improved mood, a heightened sense of competence, and better stress mitigation,” she notes. “These factors cumulatively create a psychological environment conducive to making healthier nutritional choices, reinforcing beneficial habits that may otherwise falter during adolescence, a notoriously challenging period for dietary adherence.”

Methodologically, this study is distinguished by its comprehensive longitudinal design and stringent statistical controls. While acknowledging potential unmeasured variables such as specific parenting styles or family dynamics, the investigators adjusted for numerous confounders, including parent-reported eating behaviors during childhood, socioeconomic factors, and parental marital status. This rigorous approach enhances confidence that the association between prosociality and healthy eating is not merely a reflection of shared familial or environmental influences but may represent an intrinsic health asset linked to social behavior.

Moreover, the research extends beyond establishing correlation by situating prosociality within a broader framework of health promotion strategies. Laura D. Kubzansky, PhD, MPH, of the Harvard T.H. Chan School of Public Health and co-author, champions the concept of asset-based interventions that leverage inherent strengths within youth populations. “Encouraging kindness, cooperation, and other prosocial traits aligns with youth values and fosters engagement by building upon their natural capacities,” Kubzansky argues. “Such an approach not only serves immediate social benefits but may also craft the psychological infrastructure necessary for sustained health-promoting behaviors.”

In further contextualizing the study’s implications, Dr. Qureshi reflects on contemporary societal challenges marked by division and diminished empathy. In this climate, fostering prosociality assumes added significance, offering public health stakeholders a viable, human-centered tool for intervention. “Kindness and compassion have reciprocal benefits; they uplift both the giver and receiver,” she states. “Promoting these qualities during childhood can set in motion a virtuous cycle enhancing community well-being and individual health outcomes.”

Beyond its immediate findings, this study contributes a novel dimension to the ongoing discourse about the determinants of healthy eating in youth. Traditional interventions frequently prioritize knowledge dissemination or environmental modifications. However, by demonstrating that social and emotional dispositions like prosociality materially impact dietary choices, the research invites multidisciplinary collaboration across psychology, nutrition, and public health. This integrated perspective encourages the design of multifaceted programs that cultivate not only cognitions surrounding nutrition but also the social skills and emotional capacities that underpin sustained behavior change.

Experts involved in the study underscore that adolescence constitutes a critical window during which lifelong habits are established. Dietary behaviors formed during these years bear profound consequences for chronic disease risk, including cardiovascular disease, diabetes, and obesity. The identification of prosociality as a malleable psychosocial asset expands the toolkit available to health professionals aimed at early prevention. Interventions fostering kindness, sharing, and cooperation may carry benefits extending well beyond social cohesion to tangible physiological health improvements.

While the study’s strengths include its large, representative sample and longitudinal scope, future research is warranted to unravel the precise mechanisms linking prosocial behavior with healthy eating patterns. Potential pathways include enhanced social support networks, increased exposure to positive role models, and improved emotional regulation facilitating better food choices. Additionally, research into culturally diverse populations and different socio-economic contexts will be essential to validate and adapt intervention models. The integration of biological markers could also elucidate neurobiological correlates of prosociality that influence appetite regulation and metabolic health.

In sum, the research emerging from this extensive analysis highlights prosociality as a promising health asset that may catalyze healthier adolescent development. By shifting perspective to value and enhance children’s innate strengths such as empathy and cooperation, health policy and education systems can innovate preventive strategies that speak directly to youth identities and motivations. This approach represents a paradigm shift toward a strengths-based model of health promotion aligned with humanistic values.

As public health professionals seek novel avenues to combat nutritional challenges faced by young populations worldwide, the recognition that kindness and social connection play pivotal roles provides an optimistic and actionable framework. Dr. Qureshi’s concluding reflections capture the essence of the findings: “In a fragmented world, fostering acts of genuine care and cooperation is not merely altruistic; it is a foundational investment in the health of future generations.” This study chart a compelling trajectory for research and intervention that bridges social psychology and nutritional epidemiology, heralding a new era in preventive health.

Subject of Research: People
Article Title: Kind Kids, Healthy Teens: Child Prosociality and Fruit and Vegetable Intake
News Publication Date: 11-Aug-2025
Web References: https://doi.org/10.1016/j.amepre.2025.107965
References: American Journal of Preventive Medicine, Elsevier
Keywords: prosocial behavior, childhood kindness, healthy eating habits, adolescent nutrition, longitudinal study, fruit and vegetable intake, public health, psychological functioning, health promotion, social connectedness, dietary patterns, youth development