Network analysis of school refusal behavior and internalizing and externalizing problems among Chinese adolescents

School refusal behavior (SRB) in adolescence is associated with short- and long-term adverse outcomes and frequently co-occurs with internalizing and externalizing problems. However, the intricate interrelationships among these domains remain insufficiently understood. This study aimed to explore the network structure linking SRB, internalizing problems, and externalizing problems in adolescents. A cross-sectional study was conducted in two psychiatric hospitals in Zhejiang Province, China. A total of 303 adolescents who met the criteria for SRB completed a demographic questionnaire and validated instruments assessing SRB, anxiety, depressive symptoms, non-suicidal self-injury, insomnia, and internet addiction. Network analysis was performed in R to examine the associations among SRB, internalizing problems, and externalizing problems. In the network, the strongest associations were observed between depressive symptoms and non-suicidal self-injury, as well as between anxiety and avoidance of negative emotions at school. Depressive symptoms and avoidance of negative emotions at school emerged as the most central nodes. SRB, internalizing problems, and externalizing problems were interconnected primarily through depressive symptoms, anxiety, insomnia, and avoidance of negative emotions at school. These findings underscore the central and bridging roles of key nodes linking SRB with internalizing and externalizing problems in adolescents. By clarifying the network structure underlying their co-occurrence, this study advances understanding of the interconnected psychopathological processes characterizing adolescents with SRB and highlights the clinical relevance of targeting central symptoms in intervention efforts.