Mental health problems and school performance in first graders: results of the prospective cohort study ikidS
We aimed to estimate unbiased effects of mental health problems (MHPs) on school performance in first graders, with an emphasis on rigorous adjustment for potential confounders. A population-based prospective cohort study was performed in the area of Mainz-Bingen (Germany). In 2015, all preschoolers were approached, and the presence and type of MHP (externalising/internalising) and other physical chronic health conditions were identified by the preschool health examination and study-specific questionnaires. At the end of the first grade, school performance (reading, writing, numeracy, and science) was assessed by the class teacher and rated on a four-item scale ranging from − 8 to + 8. Of 3683 children approached, 2003 (54%) were enrolled. School performance was available for 1462 children (51% boys, mean age 7.3 years). Of these, 41% had signs of at least one MHP. Compared to children without indications of mental and physical chronic health conditions, children with MHPs had lower school performance scores [adjusted mean difference − 0.98, 95% CI (− 1.35; − 0.61); P < 0.001]. Regarding the type of MHP, externalising MHPs were associated with poor school performance [adjusted mean difference − 1.44, 95% CI (− 1.83; − 1.05); P < 0.001], while internalising MHPs were not. Children with hyperactivity inattention problems were most affected [adjusted mean difference − 1.96, 95% CI (− 2.36; − 1.56); P < 0.001]. Externalising MHPs and in particular hyperactivity inattention problems may already affect school performance in early primary school. Identification of children with externalising MHPs prior to school entry may help to prevent impaired academic achievement in affected children.
KeywordsExternalising problems Attention-deficit hyperactivity disorder Academic achievement School health Community paediatrics Children
Our thanks go to the documentation specialists and student research aids for conducting the surveys and managing the data. Grateful acknowledgement goes to Katherine Taylor for proofreading as well as Jennifer Schlecht and Anna-Liesa Filbert for additional statistical analyses. Last but not least, we particularly wish to thank all the parents and children for their patience and cooperation; they made this study possible.
Members of the ikidS Project Group are Dietmar Hoffmann (Department of Public Health, County Government Mainz-Bingen), Maria Blettner, Peter Kaatsch (Institute of Medical Biostatistics, Epidemiology, and Informatics; University Medical Centre of the Johannes Gutenberg-University Mainz), Annette Queisser-Wahrendorf, Awi Wiesel, Fred Zepp, Jörg Faber, Stephan Gehring, Eva Mildenberger (Department of Pediatrics; University Medical Centre of the Johannes Gutenberg-University Mainz), Stephan Letzel (Institute of Occupational, Social and Environmental Medicine; University Medical Centre of the Johannes Gutenberg-University Mainz), Heike Elflein, Alexander K. Schuster (Department of Ophthalmology, University Medical Centre of the Johannes Gutenberg-University Mainz), Brita Willershausen, Jens Weusmann (Department of Prosthodontics, University Medical Centre of the Johannes Gutenberg-University Mainz), Christoph Matthias (Department of Communication Disorders; University Medical Centre of the Johannes Gutenberg-University Mainz), Margarete Imhof (Department of Educational Psychology, Johannes Gutenberg-University Mainz), and Perikles Simon (Department of Sports Medicine, Johannes Gutenberg-University Mainz).
This project was supported by a research grant from the German Federal Ministry of Education and Research (grant application number 01ER1302).
Compliance with ethical standards
Conflict of interest
On behalf of all the authors, the corresponding author states that there is no conflict of interest.
- 1.WHO (2003) Caring for children and adolescents with mental disorders: setting WHO directions. WHO, GenevaGoogle Scholar
- 2.WHO (2013) Mental health action plan 2013–2020. WHO, GenevaGoogle Scholar
- 3.Grant R, Brito A (2010) Chronic illness and school performance: a literature review focusing on asthma and mental health conditions. Children’s Health Fund, New YorkGoogle Scholar
- 4.Ravens-Sieberer U, Wille N, Erhart M, Bettge S, Wittchen H-U, Rothenberger A, Herpertz-Dahlmann B, Resch F, Hölling H, Bullinger M, Barkmann C, Schulte-Markwort M, Döpfner M (2008) Prevalence of mental health problems among children and adolescents in Germany: results of the BELLA study within the national health interview and examination survey. Eur Child Adolesc Psychiatry 17(1):22–33. https://doi.org/10.1007/s00787-008-1003-2 CrossRefPubMedGoogle Scholar
- 5.Currie J (2008) Healthy, wealthy and wise: socioeconomic status, poor health in childhood and human capital development. Nat Bur Econ Res, Cambridge (Working Paper No 1398) Google Scholar
- 6.Suhrcke M, de Paz Nieves C (2011) The impact of health and health behaviours on educational outcomes in high income countries: a review of the evidence. WHO Regional Office for Europe, CopenhagenGoogle Scholar
- 8.Hoffmann I, Diefenbach C, Graf C, Konig J, Schmidt MF, Schnick-Vollmer K, Blettner M, Urschitz MS, ikid SSG (2018) Chronic health conditions and school performance in first graders: a prospective cohort study. PLoS One 13(3):e0194846. https://doi.org/10.1371/journal.pone.0194846 CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Woerner W, Becker A, Friedrich C, Klasen H, Goodman R, Rothenberger A (2002) Normierung und evaluation der deutschen elternversion des strengths and difficulties questionnaire (SDQ): ergebnisse einer repräsentativen felderhebung. Z Kinder Jugendpsychiatr Psychother 30(2):105–112CrossRefGoogle Scholar
- 17.Esch P, Bocquet V, Pull C, Couffignal S, Lehnert T, Graas M, Fond-Harmant L, Ansseau M (2014) The downward spiral of mental disorders and educational attainment: a systematic review on early school leaving. BMC Psychiatry 14(1):237. https://doi.org/10.1186/s12888-014-0237-4 CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Goodman R (2000) Youthinmind Ltd. http://www.sdqinfo.org/py/sdqinfo/c0.py. Accessed 10.12.2017 2017
- 35.R-Core-Team (2017) R: a Language and environment for statistical computing. R foundation for statistical computing, Vienna, Austria. https://www.R-project.org/
- 39.Guzman MP, Jellinek M, George M, Hartley M, Squicciarini AM, Canenguez KM, Kuhlthau KA, Yucel R, White GW, Guzman J, Murphy JM (2011) Mental health matters in elementary school: first-grade screening predicts fourth grade achievement test scores. Eur Child Adolesc Psychiatry 20(8):401–411. https://doi.org/10.1007/s00787-011-0191-3 CrossRefPubMedGoogle Scholar
- 41.Galéra C, Melchior M, Chastang J-F, Bouvard M-P, Fombonne E (2009) Childhood and adolescent hyperactivity-inattention symptoms and academic achievement 8 years later: the GAZEL Youth study. Psychol Med 39(11):1895–1906. https://doi.org/10.1017/S0033291709005510 CrossRefPubMedPubMedCentralGoogle Scholar
- 45.Erskine HE, Norman RE, Ferrari AJ, Chan GC, Copeland WE, Whiteford HA, Scott JG (2016) Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry 55(10):841–850. https://doi.org/10.1016/j.jaac.2016.06.016 CrossRefPubMedGoogle Scholar
- 47.Guzman J, Kessler RC, Squicciarini AM, George M, Baer L, Canenguez KM, Abel MR, McCarthy A, Jellinek MS, Murphy JM (2015) Evidence for the effectiveness of a national school-based mental health program in Chile. J Am Acad Child Adolesc Psychiatry 54(10):799-807.e791. https://doi.org/10.1016/j.jaac.2015.07.005 CrossRefGoogle Scholar
- 48.Holling H, Schlack R, Petermann F, Ravens-Sieberer U, Mauz E, Ki GGSSG (2014) Psychopathological problems and psychosocial impairment in children and adolescents aged 3–17 years in the German population: prevalence and time trends at two measurement points (2003–2006 and 2009–2012): results of the KiGGS study: first follow-up (KiGGS Wave 1). Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 57(7):807–819. https://doi.org/10.1007/s00103-014-1979-3 CrossRefPubMedGoogle Scholar
- 50.Wilson JMG, Jungner G (1968) Principles and practice of screening for disease. Public Health Papers, vol 34. World Health Organization, GenevaGoogle Scholar
- 51.De Silva AP, Moreno-Betancur M, De Livera AM, Lee KJ, Sompson JA (2017) A comparison of multiple imputation methods for handling missing values in longitudinal data in presence of a time-varying covariate with a non-linear association with time: a simulation study. BMC Med Res Methodol 17:114CrossRefGoogle Scholar
- 54.CoCw Disabilities, CoPAo Child, Health F (1993) Psychosocial risks of chronic health conditions in childhood and adolescence. Pediatrics 92(6):876–878Google Scholar
- 56.Erhart M, Holling H, Bettge S, Ravens-Sieberer U, Schlack R (2007) The German health interview and examination survey for children and adolescents (KiGGS): risks and resources for the mental development of children and adolescents. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 50(5–6):800–809. https://doi.org/10.1007/s00103-007-0243-5 CrossRefPubMedGoogle Scholar