Longitudinal Association Between Internet Gaming Disorder and School Refusal Among Adolescents Using a Random Intercept Cross-Lagged Panel Model: Three-Wave Prospective Cohort Study.

Background: Internet gaming disorder (IGD) and school refusal are increasingly prevalent during adolescence, yet limited research has examined how they influence each other over time. Moreover, it is unclear whether the association differs by sex. Objective: This study aimed to investigate the within-person longitudinal associations between school refusal and IGD and potential sex differences in these associations among Chinese adolescent gamers. Methods: A 3-wave prospective cohort longitudinal study was conducted among students from 4 middle schools in Zhejiang Province, China. Adolescents who had played online games in the past 12 months were involved. Participants were recruited using convenience sampling. Data were collected at 6-month intervals: time 1 (T1, March 2024), time 2 (T2, September 2024), and time 3 (T3, March 2025). A total of 918 Chinese adolescents (n=609, 66.3% male; mean 13.55, SD 0.75) participated in the 3-wave survey. IGD and school refusal were assessed using the 9-item DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) IGD checklist and the School Refusal Assessment Scale-Revised. A random intercept cross-lagged panel model and multigroup analyses were conducted. Results: All statistical tests were 2-tailed with α=.05. The random intercept cross-lagged panel model demonstrated good fit to the data (χ²5=16.02; comparative fit index 0.970; root mean square error of approximation 0.035). Cross-lagged effects indicated a reciprocal association between school refusal and IGD. School refusal predicted later IGD (T1→T2: β=.06, 95% CI .02-.08; P=.02 and T2→T3: β=.06, 95% CI .02-.08; P=.02), and IGD predicted subsequent school refusal (T1→T2: β=.12, 95% CI .09-.15; P<.001 and T2→T3: β=.13, 95% CI .08-.16; P<.001). Multigroup analyses revealed significant sex differences. Wald tests showed sex-specific effects: among females, school refusal predicted later IGD (T1→T2: β=.10, 95% CI .05-.15; P=.006 and T2→T3: β=.11, 95% CI .04-.17; P=.004), whereas these paths were nonsignificant for males. IGD predicted later school refusal in both sexes, but the effect was stronger for males (T1→T2: β=.15, 95% CI .12-.18; P<.001 and T2→T3: β=.15, 95% CI .12-.18; P<.001) than females (T1→T2: β=.07, 95% CI .03-.10; P=.02 and T2→T3: β=.07, 95% CI .03-.10; P=.02). Conclusions: This study provides novel insights into the reciprocal within-person associations between school refusal and IGD among adolescents. By accounting for stable between-person differences, the model clarifies how within-person fluctuations in one behavior relate to subsequent changes in the other. Sex-specific patterns were observed: school refusal predicted subsequent IGD among females, whereas IGD predicted later school refusal more strongly among males. These findings highlight the dynamic interplay between school disengagement and problematic gaming and underscore the importance of sex-sensitive intervention strategies.