Link Between Improved Mental Health, Delaying School Start of Youngest Children and Reducing NHS Costs

smiley faceOn November 18, the Royal College of Paediatrics and Child Health (RCPCH) called on politicians to “develop an action plan… focussing on prevention and early intervention to ensure parity of esteem for children and young people” because “1 in 10 children (that’s around 3 in every classroom) have a diagnosable mental health condition“.

Coincidentally, the Journal of Child Psychology and Psychiatry just this month published ‘Children’s relative age in class and use of medication for ADHD: a Danish Nationwide Study‘, which suggests a simple and effective action plan for the improvement of summer born children’s mental health – allowing the holding back of “relatively young children” for one year.

Existing research shows that “Summer babies ‘more likely to be diagnosed with ADHD“(Telegraph, 18/09/10), “disproportionately identified as having special educational needs” (02/09), and “wrongly classed as having special needs” (28/12/12), and the Danish researchers were aware of this phenomenon too:

Previous studies from North America and Iceland have shown that the youngest children within a grade are up to twice as likely to be diagnosed and treated for attention-deficit/hyperactivity disorder (ADHD) compared with their older classmates.”

So they set out to discover whether it held true in their country too… but it didn’t.

Firstly, only 1.2% of the 932,032 eligible children received ADHD medication between 2000 and 2012, and of those that did, there was “no relative age effect” at all, which the researchers “postulate… may be due to the high proportion of relatively young children held back by 1 year in the Danish school system and/or a generally low prevalence of ADHD medication use in the country.

Interestingly, overall, “40% of children born October–December had entered school a year after their age-assigned grade level“, which tells us two things:  1) admissions flexibility for the youngest children exists, and  2) the cut-off date is more than three months after the school year starts, unlike England’s August 31st cut-off.

I found out separately, that while a typical school day in Denmark starts at 8am and finishes at about 3pm, the first three year groups usually end their day at 12pm, and also the school starting age in Denmark is higher than ours, at age 6-7.

This does not mean of course these children escape all risk of mental health problems or that ‘the Danish way’ provides a perfect panacea for our own education system, but its lack of “relative age effect” in relation to mental health could be important.

Cost Savings for the NHS

In its press release, the RCPCH also warned politicians that they “must value” children’s mental health or Britain will face “serious consequences“.

Value and consequences have more than one meaning, but while a parent’s focus might be valuing their child’s opportunity to thrive in school and wanting to avoid the well-documented consequences for some summer born children, governments will always look at the economic value of policies, and their wider social and financial consequences, too.

Understandable, yes, but in February 2009, when the NFER published its ‘International thematic probe: The influence of relative age on learner attainment and development‘ (a report commissioned by the Qualifications and Curriculum Authority, a non-departmental public body, sponsored by the DfE), it actually included this:

…two studies investigated mental health indicators. Both found evidence of significant relative age effects in measures of psychopathology and psychiatric disorders and referrals to psychiatric support services.”

1) Goodman, R., Gledhill, J. and Ford, T. (2003). ‘Child psychiatric disorder and relative age within school year: cross sectional survey of large population sample’, British Medical Journal, 327, 7413, 472–475.

Relative age was found to be an independent risk factor for psychiatric disorder after controlling for socio-demographic characteristics…  The authors conclude that their study provides ‘robust’ evidence of a link between relative age and mental health. They suggest that being youngest in the class is stressful for children. While there is a fairly ‘weak’ effect on an individual’s mental health (for example, compared to the impact of family discord or adverse life events), it could prove important for public health. For example, if all British children had the same risk of psychopathology as that identified among the oldest in the year group, around 60,000 cases of child psychiatric disorder might be prevented…

They point to the policy in New Zealand of allowing young children to progress from a preparatory class to primary school when ready and to the Scottish system whereby parents can choose to defer entry for younger children who do not seem ready for school. They recommend further evaluation (Randomised Control Trials) of the impact of allowing the youngest children experiencing difficulties to repeat the academic year or allowing deferred school entry.”

2) Menet, F., Eakin, J., Stuart, M. and Rafferty, H. (2000). ‘Month of birth and effect on literacy, behaviour and referral to psychological service’, Educational Psychology in Practice, 16, 2, 225–234.

Psychological referral analysis [in Northern Ireland where cut-off is June 30] showed that the number of referrals increased towards the May/June birth date.

So this means cost-savings not just within the education system, but also across the NHS.


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