Dispelling the nice or naughty myth: retrospective observational study of Santa ClausBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6355 (Published 14 December 2016) Cite this as: BMJ 2016;355:i6355
All rapid responses
Response in Defense of the Naughty vs. Nice Theory
Douglas Kyrouac (1)*; Iris Petersen (2)*; Andrew Houck, Pharm.D., BCPPS; Kelly Kyrouac, Pharm.D., BCPS; Jeffrey Kyrouac, MD; Matthew Helmen, MD; Kimberly Chisholm, CPA
We commend the authors’ efforts in examining a crucial topic that has previously been under explored. However, we have identified a few flaws in the methods that were used to reach the conclusion that wealth is the only determinate of whether Santa visited children in paediatric hospital wards rather than the categorization of children being naughty or nice.
First, we find issue with the measurement of "naughty": as determined by the average number of school days missed and aggregate criminal activity. Average school days missed as a proxy is inappropriate as this metric does not adequately capture the attitude of the children missing school. In a population with a larger hospital system and more sick children, the days missed are likely inflated due to illness rather than nautiness. Additionally, the authors use average criminal activity for adolescents aged 10-17 as their proxy for naughtiness. However, this age group is not reflective of the population in paediatric hospital wards in its entirety. Transition from paediatric to adult care typically occurs between 15 and 20 years of age or at the end of formal schooling. (2) This typically does include the age range examined by the average criminal activity, but that age range fails to encompass a large portion of the paediatric population. When examining what age makes up the paediatric population 8.4% of total hospital admissions are for ages 0-4, while only 3.0% of hospital admissions are for children age 5-15. (1)
Secondly, in a sample of American mall Santas (n=15), each reported their first question to children was whether they had been naughty or nice this year. Therefore, self-reporting should not be excluded from the study, as these reputable Santas take children’s self reflection into primary consideration.
Finally, many songs and tales of Santa do not claim that he visits individuals on the basis of whether these children are naughty or nice. Rather, Santa is to bring coal to those who are naughty. We see this as a complicating factor as the article did not take into account the quality of gifts but rather simply the presence or absence of a visit.
We propose that the relevance of naughty or nice in Santa's decision making process may be better evaluated by using different measures of child behavior and by including the quality of gift delivered by Santa. We would also like to echo the importance of the initial article because it calls into question the importance of children being nice throughout the year.
(1) Ohio State University College of Medicine, Medical Student
(2) Indiana University School of Medicine, Medical Student
Disclosure: Santa did visit the authors of the article in 2016.
1. Health and Social Care Information Centre. Hospital Episode Statistics: Admitted Patient Care 2012-13, 2013. http://content.digital.nhs.uk/catalogue/PUB12566/hosp-epis-stat-admi-sum...
2. Viner R. Transition from paediatric to adult care. Bridging the gaps or passing the buck? Archives of Disease in Childhood. 1999;81(3):271-275.
Competing interests: No competing interests
We congratulate Park and colleagues to propose Santa Claus (SC) priorities as a topic of research of worldwide interest . Defending innocence and the cause of children deserve our full attention in this world troubled by the “thriving cult of greed and power” of adults. However, we would like to warn that collapsing a dogma like the “nice and naughty myth” of Santa’s preference requires more appropriate study design and better data than those provided using a nationwide, ecological, hospital-based, retrospective observational study.
First, epidemiological facts are stubborn and it is likely that without individual-level indicators of child’s naughtiness the study reported in the Christmas issue of the BMJ traps into Robinson’s paradox, best known as “ecological fallacy” . Similarly, it is regrettable not to have household-level data on the socio-economic status, cultural and confessional backgrounds of the families. Thus, multilevel modelling of contextual and individual characteristics would allow to gauging the influence of social compositional effects on the likelihood of a Santa visit at area level. For instance, it would have helped to understand why North East England and North-West London had less visits [3,4]. Second, SC village is indeed located ~5 miles north from Rovaniemi, Finland (GPS-coordinates: +66° 32′ 37.11″, +25° 50′ 51.44), which is ~1,703 miles from the North Pole. Given the short distance to the UK and time to heat the reindeers, distance should be adjusted in analysis. Third, the study is hospital-based and is not representative of the community of UK children. Last, the study design is observational, which hampers causal inference and dispraises the universal mission of SC while designating one more time social health inequalities, as the risk factor to blame.
To address these important issues, we propose a multicenter population-based cluster randomised controlled trial. Primary schools will be randomised to test the effects of area-level deprivation, SC elves and local heroes (including Miss Reunion, Sitarane, footballers, hand-ballers, Maloya and Sega stars), along with naughtiness in the multicultural multi-confessional tolerant and welcoming Reunion island. Intervention arms will consist in two focus groups displaying empowerment messages in a crossover scheme (local heroes then SC elves versus alternative sequence). Crossover will be planned on October 31 to test the hypothesis that Halloween and Grand-Mother Kala  celebrations will likely influence school-age children to behave differentially before Christmas whether their parents give credit to pagan beliefs, imported or own-folk. Given the absence of difference between local heroes and SC in Park’s study , we postulate non-inferiority between intervention groups within a 1% margin.
Naughtiness will be defined as a composite indicator of individual absenteeism, master’s words in the child’s textbook and parental convocations for classroom disturbances.
SC home visits on Christmas night will be assessed as the primary outcome measure, at school re-entry in pupil’s textbook reporting the new original Santa sealed stickers found with gifts at the foot of Christmas tree. As a secondary endpoint, child satisfaction will be assessed two ways, first using a mixed methodology of qualitative interviews and measurements of the number of drawing left for SC (Fig.1) , second, by blinded elves interpreting child photographs with the help a visual analogic scale.
Data will be analysed using random-effect models with random intercept and random slopes to assess whether contextual and individual effects on naughtiness may differ between groups across schools (private catholic or public laic), parental origin, education, religions, or deciles of deprivation scores. On Reunion, altitude will be taken as a proxy of reindeer parking places and chimneys, given it correlates with population densities and temperature.
Other centres around the world wishing to share the magic of Christmas will be encouraged to reproduce the same study design, which will allow later benchmarking here-elsewhere. According to the different settings, the presence and the diameter of the chimneys and reindeers parking or other proxies will be controlled.
Data will be reported in a new international web-registry  fulfilling all security requirements to further monitoring SC temporal trends across the world.
It is the price to pay for that the “nice or naughty myth” can be dispelled, and Santa Claus reinstated in his honour. More than ever, the world of today needs mercy and forgiveness, and its children to believe their future is not conditioned from birth.
The authors who are parents thank their children for technical assistance and inspiration.
1. Park JJ, Coumbe BGT, Park EHG, Tse G, Subramanian SV, Chen JT. Dispelling the nice and naughty myth: retrospective observational study of Santa Claus. BMJ 2016; 355: i6355. http://dx.doi.org/10.1136/bmj.i.6355.
2. Robinson WS. Ecological correlations and the behavior of individuals. Am Sociol Rev 1950; 15: 351-7. http://dx.doi.org/10.2307/2087176.
3. Office for National Statistics. Regional profiles – Social indicators. http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.....
4. Alderman G. Modern British Jewry. In: Clarandon press editor. 1992, 397 pp.
5. Manglou Y. Grand-Mère Kalle. In: editions du Pailles-en-queue noir 1999, 128 pp.
6. Barata C, Yoshikawa H. Mixed Methods in Research on Child Well-Being. In: Ben-Arieh A et al. (ed.). Handbook of Child Well-Being, Springer, Netherland, 2014; 2879-2893 pp.
7. Baud D, Gérardin P, Merriam A, et al. Harness shared data in international Zika registry. BMJ 2016; 355: i5319. http://dx.doi.org/10.1136/bmj.i.5319
Fig.1 Standardized qualitative evaluation of child satisfaction after Santa Claus visit
Competing interests: No competing interests
Re: Dispelling the nice or naughty myth: retrospective observational study of Santa Claus. Fatal flaws?
The authors have made unwarranted assumptions. They seem to believe that "Santa" follows routes mapped out by the ANGLOSAXON cartographers.
And they have ignored that for centuries, Schwartze Piete in the Low Countries, as well as in the Dutch Empire and carried the gift burden of Santa. Besides Santa played the goody while Scwartze Piete was the baddy,
Competing interests: No competing interests
I congratulate the authors on this interesting study. However, I urge for a broader, more international view. The assertion that Santa Claus delivers gifts across the globe within a 24 hour period is not entirely true. In the Netherlands, e.g., Santa traditionally brings his presents on December 6th, in Russia (as "Father Frost") on January 6th, and in Germany on December 24th (Christmas Eve). The arrival of Santa in Germany on Christmas Eve is well documented since 1835 (1). Given the short period from Christmas Eve to Christmas and given that Santa has a two bases in North Germany (2), it is likely that he approaches the UK from the East and not from the North. The authors should re-analyse the flying distances under this aspect.
Santa's reluctance to fly to the UK may date back to Christmas 1940 ff. when flying obects coming from across the North Sea were hailed with an unfriendly welcome. The surprising finding that Santa thereby skips socioeconomic weak areas could have produced a feeling of being left behind in these regions. These regions to some extent match the regions that voted for the brexit (3). Hence, the authors should include the brexit voting data in the analysis. Protectionism, however, could add to the unwillingness of Santa to reliably come to the UK. The British government would therefore be wise to invite Santa Claus to the brexit negotiations.
(1) Hoffmann von Fallersleben: Unsere Volksthümlichen Lieder. Dritte Auflage. Mit Fortsetzung und Nachträgen. Engelmann, Leipzig 1869, S. 1052.
Competing interests: I do drink Coca-Cola from time to time.
This crucial and fascinating piece is fundamentally flawed in 3 important respects. First, the authors admit that some of their views are based on anecdotal evidence, and that is inexcusable. If only they had taken the trouble to consult a few of the more reliable sources, that is people like me who take on the mantle of Santa substitutes (as he is far to busy in the run up to Xmas, and asks us to represent him, without ever pretending to be the real Father Xmas.
Second, they make the totally false distinction between naughty and nice. That is an erroneous myth, and such factoids need to be corrected before they gain yet further currency. Children are never 'naughty' - they sometimes misbehave for perfectly good reason, of course, and even for not very good reason, buy there is always a reason of sorts, and medical professionals should be made to realise that. The paper's short title does go a little way to dispelling the myth, but not nearly far enough
Third, the sample is far from random, being confined to children in hospital, who are not representative. My experience, having played Santa to thousands of children over the past 10 years or so at preschools, nurseries, reception classes and public events, is very different and has evolved. I find that the answer to the question "Have you been good all year?" is better if prefaced by the instruction to be honest, which encourages many children to confess to 'minor' misdemeanours.
These comments tend to make me venture to suggest that the paper was inadequately peer-reviewed, and if so, the editors are equally to blame. There are plenty of us out there, willing and able to offer patient reviews (as I do for more serious articles). Finally, let us not forget that the real Father Xmas only ever appears on Xmas Eve when he goes to every home in the world, and is sometimes seen my the adult female in the home, when the adult male is conspicuous by his absence.
Competing interests: No competing interests
Whilst I suspect that Mr Claus would very much disapprove of 'experts' interfering by publishing this analysis of his gift deliveries, this important study raises serious concerns about his possible discrimination against children from more deprived socio-economic backgrounds. It would be interesting to consider whether, in a post-brexit 2017 Santa's attitude deteriorates yet further and he visits only hospitals in areas that voted to leave. As a country we must push for a santa that cares for all children, not just the most affluent. Medical professionals, and paediatricians in particular, must hold Santa to account for this deplorable behaviour. We can only hope that the government of the day will launch an urgent inquiry into this shocking finding.
Competing interests: No competing interests
The article containing serious allegation involving the activities of Mr Claus need to be retracted urgently
I am significantly concerned of the BMJ Editorial's decision to publish this article during this festive season. The authors may apparently have produced a scholarly work on the philanthropic behaviour of a well-respected entity but I have found their conclusions flawed and disturbing.
Although the authors acknowledge the direct reference of Mr Claus' appearance to children (less than 15 years) from an widely accepted source (ref 1) is dependent on (the child) has "been bad or good", they extrapolated the interpretation of this statement to a dichotomous relationship of "naughty or nice" to his appearance or not to the children concerned.
Although it is rational to assume that being "good" is the same as being "nice" which would presumably result in Santa coming to see the child, this belief has no foundation and no contractual obligation has ever been made in the reference document penned by John Frederick Coots and Haven Gillespie. Neither do we have any certainty that the work they supposedly authored is based on any fact and there is very little independent document which co-laterally confirm their assertion.
Furthermore the conceptual definition of being good or bad may not be what contemporary society believe it should be; it may be based on following a highly prescribed set of actions with 100% compliance, for example. An alternate interpretation can very well be that Mr Claus will only visit children whose circumstance being (of) "good" socioeconomic status, hence the flawed discussion by the authors about the inverse relationship of Mr Claus' attendance in hospitals located in geographical areas with "higher socioeconomic deprivation".
Similarly the authors' suggestions that: "potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented regions" is very disturbing. I am perturbed by their audacity to even peculate that Santa's working conditions are negotiable by anyone other than himself (and his minder/ work supervisor: Mrs Santa Claus, of course) and that his good work and reputation can be subcontracted to other beings in local deprived areas. Not only Mr Claus' work is uniquely hazardous, requiring occupational health clearance to exacting standards and regular psychometric assessment for a highly stressful work at night out of 365 days, the acute lack of hospital parking for land vehicles driven by mere mortals will only result in prolonged duration of unaccredited unregulated and unqualified local "Santas" driving around the block looking for empty car spots without trespassing or breaching the traffic code, the penalties often administered by unforgiving BPA Approved Operators even on Christmas Eve. Surely there is a reason why Mr Claus chose to travel by a flying snow sleigh led by reindeers Dasher, Dancer, Prancer, Vixen, Comet, Cupid, Dunder and Blixem (it is debatable if there is ever a reindeer called Rudolph - Ref 2)
I call for the emergency extraordinary meeting of the guarantors/directors of the BMJ to review the serious lapse in the judgement of BMJ editors in their decision to publish this libelous article and consider the necessary action required to defend themselves from the legal representatives of Claus & Elfs Limited (incorporated in Magnetic North)
Competing interests: I have never seen Santa Claus for many many many years.