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Rapid Responses: Rapid Responses published:
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Holding Back May Cause More Harm
- Thomas E. Radecki (29 August 2003)
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Peer effects and mental health promotion in schools
- Woody Caan (30 August 2003)
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Re: Holding Back May Cause More Harm
- Robyn M. Greenwell (30 August 2003)
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Meeting children's needs .
- Jolanda Challita (31 August 2003)
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What Are the Specific DSM4 Psychiatric Diagnoses?
- Dr P V Finn Cosgrove (1 September 2003)
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Importance of preterm birth
- Stefano Palazzi (2 September 2003)
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Relative age suggests a transactional process
- Laurence Jerome (2 September 2003)
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Thomas E. Radecki, Private practice psychiatrist Urbana, IL 61801
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If the increased level of psychiatric stress found in the relatively younger students is the result of inappropriate expectations on the part of teachers or the absence of streaming students by ability, holding back students may have no net beneficial effect. The held back student will now become one of the older students in the class making all the other students relatively younger than they were before and making them appear of lower ability when compared to the new elevated average. This may increase the stress on them, and result in no net gain in psychiatric well -being. Indeed, some held back students may be resentful and increase stress both in the held back student and in the classroom. I would point out that at least in the United States, school systems often have a conflict of interest on the holding back issue, since holding a child back will very likely increase the number of years that child is in that particular school system and, therefore, increase the amount of government funding that school system will receive if there is a capitated reimbursement system. Since I have personally witnessed students denied early graduation for just this reason, I would not dismiss it too readily. Students who are held back are injured in at least one way. They are stuck in an extremely lengthy educational system one extra year and denied one extra year of occupational income and freedom from schooling. A sizeable number of American studies have found no psychological harm associated with the grade acceleration of the more academically capable students. Indeed, only one study detected any difference and it found that gifted students who were not grade accelerated suffered more psychological difficulties. I fear the BMJ study, with its simply remedy of holding back, may be used by some less than perfect teachers to hold back many students unnecessarily. While I applaud the study for better documenting a problem, I would note that there is absolutely no research showing that holding back on strictly psychiatric grounds helps any student, let alone which students. Therefore, I am troubled by its promotion in the article as a primary remedy. While I think there almost certainly are psychiatric situations for holding back, we must remember that harm is also possible. Unfortunately, here in the U.S., there is often a very politically correct hostility against streaming students by their abilities and against grade acceleration. In view of the strong dysgenic effect of college education on the more academically gifted around the world, we need to find ways shorten the amount of time college bound students are forced to spend in school, so that they may have more time to earn money and have larger families than they currently do. I fear this article will be used to increase resistance against grade acceleration and to hold students back simply because they are "more immature," and not because they have any increased psychiatric difficulties. Obviously, my 13 year old daughter is more immature physically than the other freshmen in her college classes, but that doesn't mean she would have benefited from being held back. Competing interests: None declared |
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Woody Caan, Professor of Public Health Department of public and family health, APU, Chelmsford, Essex CM1 1SQ.
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Congratulations to Professor Goodman and colleagues (1)on an excellent demonstration of the way that small effects at an individual level can create significant opportunities at the population level for public health interventions. It is possible, as they suggest, that it is the differential behaviour of teachers towards slightly younger pupils in the classroom that increases their risk of developing mental health problems. However, there are other players learning their parts in the classroom drama: the older children. As professionals and adults it is easy for us to neglect the longterm impact of early social adversity (2) but patterns of bullying and sexual aggression can undermine mental wellbeing in the school age population. At five, if there are going to be targets for classroom bullying, the younger (smaller, less articulate, less assertive) child may be at greatest risk. At eleven-plus, the young people who reach puberty first may show aggression towards their less developed classmates. Most children do not experience trauma during "the best years of their lives", but for some The Lord of the Flies can be closer to their experience of schooldays. Where young people do become trapped in harmful social situations, it is possible that quite subtle differences in age and development could increase the risks. However, this growing knowledge base (1) around child development and life trajectories could also improve our interventions to promote mental health. 1 Goodman R, Gledhill J, Ford T. Child psychiatric disorder and relative age within school year: cross sectional survey of large population sample. BMJ 2003; 327: 472-475. 2 Caan W. Good for mental health - an academy for the social sciences. Journal of Mental Health 2000; 9: 117-119. Competing interests: Chair of the School Health Research Group, 2001-2003 |
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Robyn M. Greenwell, parent Newcastle, NSW Australia 2303
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It was intersesting to read a US perspective on this issue. Here in Australia, holding back is very much encouraged by education authorities and the media, and is deemed almost mandatory for boys, who are regarded as suffering far more disadvantage from "early" school starts. In my State, the school year begins in late January, and a child may start if they have turned 5, or will turn 5 by the end of June, but many are held back until the following year, resulting in a possible age spread of 18 months within a single class. This situation would appear to put even more emphasis on the need for teachers to be aware of the differing ability levels within their classroom. However, it is parents and parental attitude to schooling which are generaly portrayed as the major cause of disfunction in children. The Sydney Morning Herald ran a brief report on this resech paper (It can be viewed at > http://www.smh.com.au/text/articles/2003/08/29/1062050664727.htm ) Despite the fact that authors Goodman, Gledhill and Ford made no mention of parents as a risk factor in the development of a child's psychiatric difficulties, the Herald report suggests that "pushy" parents with unrealistic expectations for their children's academic success are the primary cause of the disfunction reported in the original paper. This is quite typical of media attitudes and public perception here. Thomas Radecki suggested that in the US gifted children who would benefit from academic acceleration may be held back by school administration. In Australia, such children are often held back because parents fear the social disapproval that results from suggesting that a gifted child has different educational needs. Unfortunately, it appears that this paper is already on its way to becoming part of the justification for forcing academicaly gifted children into lockstep progression with their age peers. Competing interests: None declared |
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Jolanda Challita, Parent 2228
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The study said that: "Teachers often forget to make allowances for a child's relative age"!.... It appears that they also forget to make allowances for a child's educational needs, intellectual potential and already obtained academic ability. Children are not regarded as individuals in education. Being the youngest in the year is only associated with educational disadvantage if the teacher does not make allowances for a child's ability or needs. Its not the parent that has the unreasonable expectation, its the system as it expects everybody to function at a certain level at a certain age in their life regardless of their intelligence, ability, need, personality or situation. Grouping children by relative age would only help the solve the problem if all those children at that particular age were at the exact same level and stage of their educational, social and emotional development and have the same needs that need to be met. Children need to have their particular educational needs met to be happy and fulfilled in their education. Meeting children’s age requirements is, in the large majority of cases, not meeting the child’s educational needs and is very damaging to a child’s self esteem and feelings of self worth which in turn affects them psychologically and emotionally. Surely a more sensible approach would be to start children at school when they are emotionally and socially ready to start school and then put the children into classes at a level that is appropriate and suitable to their ability and need. Competing interests: None declared |
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Dr P V Finn Cosgrove, Consultant All-Age Psychiatrist The Bristol Priority Clinic, BA2 5YD
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Goodman R, Gledhill J & Ford T have studied almost 10,500 school children, and they have concluded that younger children in the school year are more likely to have a psychiatric diagnosis (BMJ 2003;327:472-5). They say that the youngest third of children in a school year have a psychiatric diagnosis at the rate of 9.9%, compared to 8.8% for the middle third and 8.3% for the oldest third in the school year. These percentages are for their "Any Psychiatric Diagnosis" category. The statistical significance for these three percentages for "Any Psychiatric Diagnosis" is P = 0.03 (significant). This is not nearly as high a level of statistical significance compared to the 0.001 (very highly significant) which they get for both the parent and for the teacher reported symptoms for All Ages and for the 5-10 year old group. Please will Goodman R et al provide us with the breakdown they must have of this "Any Psychiatric Diagnosis" category they use. Please will they post on the BMJ website the percentages for each of the three thirds of a year in each of the three age categories for each and every psychiatric diagnosis by name. It is important for the rest of us, especially clinicians, to know which psychiatric diagnoses were more common and which were less common. I suggest that the category of "Any Psychiatric Diagnosis" may not be very helpful, although I suspect that the limitation on space in the journal may have required this "mixed-bag" category from them. If the Editor cannot accept a full breakdown of the "Any Psychiatric Diagnosis" according to the specific DSM4 diagnosis, then please would the authors email this data to me, and we can then discuss it on bmj.com. This is an important study and deserves discussion. Please may we have this data within the next seven days. Competing interests: None declared |
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Stefano Palazzi, Consultant Child and Adolescent Psychiatrist South-Essex Partnership NHS Trust, Great Oaks, Basildon SS14 1EH
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The article by Goodman et al. does not mention the main clinical issue that clinicians meet regarding children born just before the watershed of the school year. When they are born with a gestational age below 32 weeks, they carry compounded risks of developing psychiatric disorders. One source of risk is that childhood and adult mental health illness is associated with some of the same neuro-developmental factors that cause preterm birth. A second source of risk is that when these biologically immature children enter school they are allocated to the previous school year not just for a few weeks or months of difference, but it may be up to 16 months. Finally, the interaction of environmental (parents) expectations with a child biologically at risk may become quite complex, depending on a number of family variables. We are talking of all children born in August and due by December in the UK and children born preterm at Christmas time in Sweden, Italy and elsewhere. It is a small percentage in the general population but it is likely that they are overrepresented in child mental health and learning disability services. It is then plausible that if the published study had taken into account preterm births, stronger correlations could have been found for this subgroup. On a total population, individual pupils and schools variability may have shadowed the point that the study could have contributed to make more clearly. What the article says, in my view, is that children should be considered for their individual developmental maturity, rather than be expected to conform to one-size-fits-all educational policies. Chronological age is just a proxy measure of biological age. Developmental issues may not be tackled by administrative shortcuts. Obviously the latter can help, especially when the role of cognitive aspects (not directly observable) are overshadowed by behavioural and emotional manifestations (speaking by themselves). Competing interests: None declared |
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Laurence Jerome, Consultant Psychiatrist Amethyst Demonstration School
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The authors data suggests that the relative age effect is more apparent for teacher than parent ratings.This would imply a situational factor in play. As Prof. Caan points out in his response,the impact of a constitutional vulnerability such as shyness &/or learning disability transacting with ordinal position within the class would help define a "target" population more vulnerable to the negative attention of a proportion of the older cohort, some of whom will be bullies. There is no empirical evidence that simply delaying school entry or repeating the year will address these "relative age" effects. Clinical experience demonstrates that the solutions for an individual child will depend on many "bio-psycho-social" factors. The reduced opportunities for segregated classes for some vulnerable children have been evident in my practice in recent years. Whilst the authors present a range of solutions to address the relative age effect, I think we need to better understand the different patterns of psychopathology which are not readily visible in the data as presented. This might suggest different psychopathological mechanisms in different sub-groups of this large data set. Laurence Jerome Competing interests: None declared |
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