Associations of Parental Distress and Behavior with School Readiness in Children Born Very Preterm.

OBJECTIVE: Children born very preterm (VPT; gestational age [GA] <31 weeks) have robust school readiness difficulties relative to children born full-term (FT; GA ≥37 weeks). This study examined whether four aspects of parental well-being and behavior-distress, harshness, responsiveness and positive control, and cognitive stimulation-were linked to school readiness in a sample of children born VPT <31 weeks GA and whether these characteristics similarly impact VPT and FT children. METHODS: Parents of 4-year-olds born VPT (n = 55) and FT (n = 38) reported on parental distress, behavior, and cognitive stimulation. Children's cognition, executive function, motor skills, preacademic abilities, and behavior were assessed via neuropsychological tests and parent-report questionnaires. RESULTS: For both groups of children, higher psychological distress and harshness were associated with more behavior problems, and more cognitive stimulation was associated with higher scores on tests of cognitive, motor, and preacademic abilities. More parental distress was associated with lower cognitive ability only for children born VPT and more harshness was associated with lower preacademic skills only for children born FT. CONCLUSIONS: Identifying modifiable family factors associated with school readiness in children born VPT is essential for informing family-based interventions to improve school readiness in this population. Findings suggest that distress, harshness, and cognitive stimulation may be reasonable targets for interventions to improve school readiness in children born VPT.

Parent Perspectives of School/Daycare Experiences in Young Children Newly Diagnosed With Diabetes.

OBJECTIVE: A central part of family adjustment to a new diagnosis of type 1 diabetes (T1D) is integrating T1D management into the child's school/daycare. This may be particularly challenging for young children who rely on adults for their diabetes management. This study aimed to describe parent experiences with school/daycare during the first 1.5 years following a young child's T1D diagnosis. METHODS: As part of a randomized controlled trial of a behavioral intervention, 157 parents of young children with new-onset (<2 months) T1D reported on their child's school/daycare experience at baseline and at 9- and 15-month post-randomization. We used a mixed-methods design to describe and contextualize parents' experiences with school/daycare. Qualitative data were collected via open-ended responses, and quantitative data were collected from a demographic/medical from. RESULTS: While most children were enrolled in school/daycare at all time points, over 50% of parents endorsed that T1D affected their child's enrollment, rejection, or removal from school/daycare at 9 or 15 months. We generated five themes related to parents' school/daycare experiences: Child factors, Parent factors, School/Daycare factors, Cooperation between Parents and Staff, and Socio-historical factors. Parents of younger children and those with lower subjective socioeconomic status were significantly more likely to endorse challenges with school/daycare enrollment. CONCLUSIONS: School/daycare settings present challenges for parents of young children with T1D. Changes may need to occur across contexts to support early childhood education, including advocacy resources for parents to navigate school policies, increased training for school staff, and healthcare team outreach initiatives to parents and schools.

Establishing the Content Validity of a Modified Bank of School Anxiety Inventory Items for Use Among Adolescents With Chronic Pain.

OBJECTIVE: School anxiety is a prevalent mental health concern that drives school-related disability among youth with chronic pain. The only available measure of school anxiety-the School Anxiety Inventory, Short Version (SAI-SV)-lacks content specificity for measuring school anxiety in pediatric pain populations. We aimed to refine the SAI-SV by obtaining qualitative data about unique school situations that are anxiety-provoking for youth with pain and characterizing the nature of symptoms experienced in these situations. METHODS: Adolescents with chronic pain (n = 16) completed a semistructured interview focused on experiences with anxiety in school-related academic and social contexts. We employed thematic analysis to extend the empirical understanding of school anxiety from the perspective of patients suffering from pain and to generate new item content. The content was refined with iterative feedback from a separate group of adolescents with chronic pain (n = 5) and a team of expert pain psychologists (n = 3). RESULTS: We identified six themes within the data and generated new items designed to capture anxiety related to negative interactions with teachers and peers, falling behind with schoolwork, and struggles with concentration and fatigue. Participants and experts rated new item content as highly relevant for use among youth with pain. The updated item bank was named the School Anxiety Inventory for Chronic Pain. CONCLUSIONS: Future research is needed to complete the psychometric evaluation of the item bank and finalize items to be included in a measure that can be used in research and clinical settings. Implications for treating school-related anxiety among youth with pain are also discussed.

Childhood Cancer Survivors and Distance Education Challenges: Lessons Learned From the COVID-19 Pandemic.

OBJECTIVE: Pediatric cancer survivors have historically struggled to receive adequate educational supports. In Spring 2020, the COVID-19 pandemic forced an emergency switch from traditional in-person education models to distance education, but little information is available regarding experiences of pediatric survivors' coping with schooling since that time. METHODS: This article presents exploratory mixed methods findings from a quality improvement project including qualitative interviews and a quantitative survey conducted with parents of pediatric oncology survivors identified through neuropsychological assessment, and the use of school-based services as having educationally relevant neurocognitive impacts of disease or treatment. The interviews explored experiences of education and instructional delivery during the COVID-19 school closures in spring of 2020 and the beginning of the 2020-2021 school year and served as the foundation for a quantitative survey to determine the generalizability of findings. RESULTS: Qualitative interviews highlighted 3 emergent themes regarding the shared experiences of distance schooling for children with cancer during the COVID-19 school closures: (a) attention, (b) mental health, and (c) access to instruction. A follow-up quantitative survey supported the qualitative findings and their generalizability to the schooling experiences of other children with cancer during the pandemic. CONCLUSION: This article describes and explores each theme and offers suggestions for pediatric supports and changes to provider service delivery (including weblinks to access project-developed resources) as a result of ongoing pandemic-related schooling needs.

COVID-19 Pandemic: Mental Health in Girls With and Without Fragile X Syndrome.

OBJECTIVE: Children and adolescents, who have less developed coping skills, are affected by natural disasters and other traumatic events differently than adults. Emotional and behavioral effects are particularly pronounced during a pandemic-related disaster, when support networks that typically promote healthy coping, such as friends, teachers, and family members, may be less available. Children and adolescents with fragile X syndrome (FXS), who are at increased risk for developing anxiety and depression, may be particularly vulnerable to behavioral or emotional difficulties during a pandemic. This study examined the mental health outcomes of school-aged girls with FXS during the COVID-19 pandemic and associated stay-at-home orders. METHODS: Participants included 47 school-aged girls with FXS and 33 age- and developmentally matched comparison girls. Associations between COVID-19 behavioral and emotional outcomes and prior academic, adaptive, behavioral, and emotional functioning as well as prior maternal mental health and characteristics of the mother-child relationship were examined. Qualitative data from the parental report of emotional and behavioral responses to the pandemic were also obtained. RESULTS: Results indicate that school-aged girls with FXS demonstrate a distinct profile of COVID-19 related associations compared to the comparison group, such that pandemic-related worries and emotional impact of pandemic restrictions were predicted by prior mental health factors for the comparison group but by prior social, behavioral, and relational factors for the FXS group. CONCLUSIONS: Findings provide insight into factors that may confer risk or resilience for youth with special needs, suggesting potential therapeutic targets and informing public health initiatives in response to the pandemic.

Early executive and school functioning: Protective roles of home environment by income.

This study used data from the Family Life Project (N=1,227), a longitudinal study of child development. We tested a three-way interaction in which positive parenting and learning materials in the home from age 6-36 months and family income predicted children's executive functioning (EF) at 58 months. We also tested whether this interaction predicted early school functioning, specifically behavioral and academic skills in the 1st grade. The interactive effects of positive parenting and learning materials differed by family income. For children in families of lower income, more learning materials and positive parenting predicted better EF, and in turn, better early school functioning. For children in families of higher income, only positive parenting significantly predicted EF, which in turn, predicted better early school functioning. Findings suggest that more targeted policy and program support for enrichment and positive parenting may bolster efforts to combat poverty.

Exploring the Prevalence of Pediatric Chronic Pain and School Absenteeism for Therapists Working in Schools: A Systematic Review with Meta-Analysis.

AIM: To explore the prevalence of school absenteeism for children with chronic pain and to identify the characteristics of children with chronic pain who report absenteeism. METHODS: Systematic review with meta-analyses of quantitative studies. Studies were included if they reported mean days absent from school in children with chronic pain aged 5-18 years, attending a full-time school program. Quality of evidence was assessed using the Mixed Methods Appraisal Tool. Participant characteristics of age, gender, pain duration, pain type, and data collection setting were collated. RESULTS: Eighteen quantitative studies involving 2963 children with chronic were included. Studies had moderate to high quality of evidence. Meta-analysis demonstrated 13.28 mean days were spent absent from school in a 60-day period (95% CI 10.21, 16.34) (p < 0.001). Participants were predominantly females (71.8%) aged 14.1 years (SD 2.32). The most experienced pain type was combined headache or head pain (46.9%) and average duration since pain onset was 32.5 months (SD 36.34). CONCLUSIONS: Children with chronic pain aged 5-18 years are absent for approximately 22% of school days, in a 60-day period. Early, targeted intervention for absenteeism and poor school functioning is recommended. Future research could evaluate the role of school-based therapists in screening at risk students and improving attendance and outcomes.

Social-ecological predictors of school functioning in Hispanic children treated for cancer with central nervous system-directed therapies.

BACKGROUND: Children with brain tumor or acute leukemia are at risk for neurotoxic side effects associated with their cancer therapies. These long-term deficits include poor health-related quality of life (HRQOL) in school and lower educational achievement. Although social-ecological factors may impact these outcomes, it is not known which factors play a role. Our objective was to evaluate the factors affecting school HRQOL in Hispanic childhood cancer survivors, an important at-risk group. PROCEDURE: Multivariable regression analyses examined whether selected social-ecological factors contribute toward suboptimal school HRQOL in 73 Hispanic children treated with central nervous system (CNS)-directed cancer therapies after accounting for effects associated with established cancer-related risk factors. RESULTS: Consistent with expectations from prior research, in our multivariate analysis, the cancer-related factors of having a brain tumor diagnosis and being younger at cancer diagnosis were significant predictors of reduced parent-reported school HRQOL (F(2,65) = 5.46, P < .01) and accounted for 14% of the variance. Adding the social-ecological variables of parent education, child motivation, and parental knowledge accounted for an additional 25% of the variance in school HRQOL, where higher levels were associated with better child school HRQOL. Parenting knowledge was a contributor even after controlling for effects associated with the other variables in the model (F(1,62) = 4.88, P < .05). CONCLUSIONS: Cancer survivorship care should incorporate parent education interventions to enhance the child's school functioning, particularly for Hispanic childhood cancer survivors from predominantly Spanish-speaking families. Future research should consider other at-risk groups and incorporate social-ecological indicators to predict HRQOL outcomes.

A systematic review of the impact of chronic pain on adolescents' school functioning and school personnel responses to managing pain in the schools.

AIMS: To critically synthesize empirical studies on the impact of chronic pain on adolescents' school functioning and school personnel responses to managing pain in schools. DESIGN: Mixed method systematic review. DATA SOURCES: Medline, CINAHL, PsycINFO, ERIC, ScienLO, Cochrane Library, and EMBASE were searched for published articles from inception to December 2018. REVIEW METHODS: Fourteen studies met the inclusion criteria. Data from the qualitative and quantitative studies were synthesized using parallel-results convergent integrated design. The Critical Appraisal Skills Programme and Mixed Methods Appraisal Tool version 2018 were used for assessing the quality of included studies. RESULTS: Chronic pain appears to have a significant negative influence on adolescents' school attendance, academic performance/achievement, academic competence, physical activities, and social functioning. However, other studies indicated that adolescents with chronic pain had better academic performance and competence than healthy peers and that chronic pain did not affect older adolescents' social functioning. There is limited guidelines and resources for how school personnel can help adolescents to manage pain in schools. CONCLUSION: This review supports the need for future research on the impact of adolescents' chronic pain on the full dimensions of school functioning and to identify the effective responses of school personnel to managing adolescents' pain in schools. IMPACT: Although findings are somewhat conflicting, overall adolescent's chronic pain appears to have a negative influence on school functioning. Yet limited guidelines exist for how school personnel should respond effectively to manage adolescents' pain in schools. The review indicates the importance of written policies to guide teachers on how to facilitate optimal pain management in schools. It also highlights the significance of clear communication between healthcare professionals and school personnel, adolescents with chronic pain and their parents to support optimal school functioning.

Learning outcomes of children with teacher-identified emerging health and developmental needs.

OBJECTIVES: Children's additional health and developmental needs are often first identified by teachers when they begin school. This study estimates the Grade 3 literacy and numeracy outcomes of children with teacher-identified additional needs emerging in the first year of school, including the added burden conferred by socioeconomic disadvantage. METHODS: Population linked data (n = 42,619) were analysed from the Australian Early Development Census, which include teacher reports on children's health and development at school entry, and the National Assessment Program-Literacy and Numeracy, a direct assessment of reading and numeracy skills at Grade 3. Linear regression analyses were used to estimate associations between emerging needs and learning outcomes, adjusted for sociodemographic characteristics. The combined effect of emerging needs and low maternal education (an indicator of socioeconomic disadvantage) on academic outcomes was examined by estimating the relative excess risk due to interaction (RERI). RESULTS: Emerging health and developmental needs at school entry were associated with lower reading (b = -26.86, 95% CI = -29.19, -24.52) and numeracy (b = -24.39, 95% CI = -26.43, -22.35) outcomes at Grade 3. The combined effect of emerging needs and socioeconomic disadvantage was greater than expected when their individual effects are summed (RERI = 0.38, 95% CI 0.22, 0.55 for reading and RERI = 0.27, 95% CI 0.10, 0.43 for numeracy). CONCLUSION: In the current study, emerging health and developmental needs identified by teachers at the outset of schooling were associated with poorer literacy and numeracy skills at Grade 3, and family socioeconomic disadvantage appeared to further amplify this effect. Meeting the needs of these children will require timely and coordinated supports across the health and education systems, particularly for those children who are also disadvantaged.

Children's Emotional Self-Regulation in the Context of Adversity and the Association with Academic Functioning.

The aims of this study were to study reciprocal interactions between emotion regulation skills, association of these skills with children's school functioning and how these underlying skills develop in children in the context of adversity. 48 children (mean age = 5 years 8.2 months) were divided into an adversity risk group and a low-risk group. Emotional regulation was assessed via an emotion identification task, a Stroop task and near-infrared spectroscopy. School functioning was documented using the Social Skills Improvement System with parents and teachers. During the Stroop task, there was a difference in the activation of the right Brodmann area 8 in both groups. During the emotion regulation tasks, BA8L and BA9R showed activation and an association with school functioning. These results contribute to the accuracy of cerebral mapping associated with emotion regulation and support its potential contribution in preventive programs aimed at the functioning of children at risk of school difficulties.

Gender-Typed Personality Qualities and African American Youth's School Functioning.

Numerous studies document sex differences in African American girls' and boys' academic achievement and motivation, but little is known about how the enactment of gender, such as in the forms of gendered behaviors, attitudes, or personal-social qualities, is related to school functioning. To advance understanding of African American adolescents' academic experiences, this study examined the longitudinal linkages between stereotypically feminine (i.e., expressive) and stereotypically masculine (i.e., instrumental) personality characteristics and school adjustment. The moderating effects of youth's ethnic identity and school racial composition also were tested. Participants were 352 African American youth (50.1% girls; mean age at Time 1 = 12.04 years; SD= 2.03) who participated in annual home interviews. Net of biological sex, expressive traits (kind, sensitive) were positively related to school self-esteem and school bonding for both girls and boys, but youth with higher levels of instrumentality (independent, competitive) exhibited sharper declines in academic achievement across adolescence. School racial composition moderated the effects of instrumentality at the between-person level, such that instrumentality was positively related to school self-esteem only for youth who attended schools with fewer African American students. These results highlight the importance of incorporating gendered personality traits, rather than biological sex alone, into theoretical accounts of African American youth's school functioning.

Psychological Distress in Parents and School-Functioning of Adolescents: Results from the World Trade Center Registry.

Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.

School Self-Concept in Adolescents With Chronic Pain.

Objective: This study investigated school self-efficacy and sense of school membership (collectively "school self-concept") as potential influences on impaired school function among adolescents with chronic pain, including comparison of adolescents with primary pain to those with disease-based pain and pain-free peers. Methods: In all, 264 adolescents (12-17 years old) with primary pain conditions, juvenile idiopathic arthritis, or no pain completed measures of functional disability, school functioning, pain characteristics, and school self-concept, the Self-Efficacy Questionnaire for School Situations (SEQ-SS), and Psychological Sense of School Membership (PSSM). Results: Both the SEQ-SS and PSSM demonstrated reliability and some validity, with the SEQ-SS more strongly supported. As a group, adolescents with primary pain conditions reported poorer school self-concept. School self-efficacy, but not school belongingness, predicted school functioning later in the school year. Conclusions: School self-concept, especially as assessed with the SEQ-SS, is relevant and important to assess when addressing school functioning in youth with chronic pain.

Associations between mothers' active engagement with infants at 6 months and children's adjustment to school life at ages 5.5 and 11 years.

BACKGROUND: In Japan, students' poor adjustment to school life such as school refusals has been recognized as a nation-wide problem. In this study, we examined the link between the absence of mothers' active engagement with their infants at 6 months and children's risks of poor adjustment toward elementary school life at the ages of 5.5 and 11. METHODS: We used a Japanese national longitudinal survey (n = 43 132) with 11 years of follow-up. Because of social patterning in how mothers engage with their infants, we employed propensity score matching analyses to control for confounding by socio-economic and other factors. We matched mothers with active engagement and those without on various social and parental characteristics such as educational attainment and household income. RESULTS AND CONCLUSIONS: Among matched pairs, we observed higher risks of poor adjustment to school life at both 5.5 and 11 years among Japanese children who lacked mothers' active engagement at 6 months. For example, the relative risk was 1.46 [95% confidence interval: 1.10, 1.94] for inability to get along with others in a group setting at the age of 5.5 years and 1.29 [1.10, 1.51] for inability to get along with teachers at the age of 11 years. Our findings corroborate previous findings, which emphasize the importance of providing an enriched environment for infants' social development and may indicate the need for an intervention for caregivers who lack appropriate nurturing skills.

Investigating a Proposed Model of Social Competence in Children With Traumatic Brain Injuries.

OBJECTIVE: The goal of the current study was to test a proposed model of social competence for children who have suffered a traumatic brain injury (TBI). We hypothesized that both peer and teacher reports of social behavior would mediate the relation between intraindividual characteristics (e.g., executive function) and peer acceptance. METHODS: Participants were 52 children with TBI (M age = 10.29; M time after injury: 2.46 years). Severity of TBI ranged from complicated mild to severe. Classroom and laboratory measures were used to assess executive function, social behavior, and peer acceptance. RESULTS: Analyses revealed that peer reports of social behavior were a better mediator than teacher reports of the associations between executive function, social behaviors, and peer acceptance. DISCUSSION: The results underscore the importance of including peer reports of social behavior when developing interventions designed to improve the social, emotional, and behavioral outcomes of children with TBI.

Parent and teacher perceptions of emerging special health care needs.

AIM: A fifth of children enter school with special health care needs (SHCN) impacting on their physical, psychosocial or educational development, including many with emerging SHCN who often do not qualify for additional supports. This study aimed to compare the perceptions of parents and teachers on children's emerging SHCN, and explore correlates of conflicting reports. METHODS: The Longitudinal Study of Australian Children (LSAC) is a nationally representative study of Australian children, which includes the abbreviated Children with Special Health Care Needs Screener. Data were analysed from a subsample of n = 720 children from the LSAC Kindergarten cohort (n = 4983) for whom teachers also completed the Australian Early Development Index checklist, a measure of early childhood development that includes teacher reported SHCN. RESULTS: Teachers (n = 120, 17.34%) identified more emerging SHCN than parents (n = 74, 10.74%), and reports were often discrepant. Children were more likely to have consistent reports of emerging SHCN when their parents had high levels of involvement at school (OR 4.86; 95% CI 1.08-21.80; P < 0.05), whereas children who came from disadvantaged family backgrounds were more likely to have teacher-only identified difficulties (OR 3.66; 95% CI 1.17-11.50; P < 0.05). CONCLUSION: Parents and teachers bring different perspectives to children's development and additional support needs, each of which is valuable. Greater attention should be given to ensuring that common understandings about a child's needs at school are established early in children's educational pathways.

Transactional Links Between Teacher-Student Relationships and Adolescent Rule-Breaking Behavior and Behavioral School Engagement: Moderating Role of a Dopaminergic Genetic Profile Score.

Throughout adolescence, there is an increase in rule-breaking behavior and a decrease in behavioral school engagement. The role of teacher-student relationship quality in the development of these adjustment problems remains understudied. This study examined how adolescent-reported teacher-student affiliation and dissatisfaction and parent-reported rule-breaking behavior and behavioral engagement impact one another throughout adolescence. In addition, we examined the moderating effect of genes by means of a Biologically Informed Multilocus genetic Profile Score (BIMPS), a composite score reflecting the cumulative effect of multiple dopaminergic genes, with a higher score indicating higher dopamine signaling in the adolescent brain. We used three-year longitudinal data from 1111 adolescents (51 % boys; M age = 13.79), and their parents. Cross-lagged analyses revealed a transactional process in which adolescents who display more rule-breaking behavior and less behavioral engagement experienced increased subsequent dissatisfaction with their teachers, which in turn further increased their adjustment problems. Also, adolescents with more adjustment problems experienced decreased subsequent affiliation with their teachers. The other way around, adolescents' behavioral engagement also benefitted from positive relationships with teachers. Multi-group analyses revealed genetic moderation for behavioral engagement, but not for rule-breaking. Specifically, adolescents who had a BIMPS score coding for moderate levels of dopamine signaling (instead of high or low signaling) were most affected in their behavioral engagement when they experienced dissatisfaction with their teachers. Our study findings may guide schools in implementing interventions to create a supportive class and school environment including positive, supportive teacher-student relationships and indicate that providing a such a supportive school environment is important for all adolescents.

Centering Patient and Clinician Voices in Developing Tools to Address Pain Related School Impairment: A Phase I Study of a Virtual Reality School Simulation for Children and Adolescents with Chronic Pain.

Building on growing evidence supporting virtual reality (VR) interventions for pain management, this study describes the process of developing vReal-School (vRS), a VR-based school simulation for children and adolescents with chronic pain and associated school impairment. Following guidelines for developing user-centered VR interventions, initial phases of intervention development focus on understanding and incorporating patient and clinician perspectives when designing this digital health tool. Phase I entailed focus groups with patients undergoing intensive interdisciplinary pain treatment (IIPT). A total of 19 participants across four focus groups shared their experiences related to dealing with pain at school and provided initial feedback on the concept of a VR-based school simulation. In phase II, we pilot-tested a vRS prototype and collected patient and clinician feedback via mixed method approaches. Phase I results highlight four themes related to pain in school, including physical/environmental challenges and solutions, academic challenges and solutions, peer interaction challenges and solutions, and teacher interaction challenges and solutions. These themes guided the development of our vRS prototype. Nine patients and eleven treating clinicians then engaged with the vRS prototype and provided feedback via semi-structured interviews and validated self-report measures. The results indicate high levels of patient engagement/immersion (mean total score of 17.0 on the Child Presence Measure). Qualitative feedback from both groups identified positive aspects of vRS, including finding the simulation realistic and easy to use and offering ways to address school functioning goals that are not otherwise feasible in the IIPT setting. Areas for improvement included integrating more physical movement as well as increasing the number of scenarios and the level of demands of the tasks available. Both patients and clinicians found vRS to be useful in the IIPT context and relevant to treatment goals. This user input will guide subsequent iterations of intervention development.

Externalizing problems mediate the relation between teacher and peer violence and lower school performance.

BACKGROUND: The association between children's exposure to family violence and poor academic outcomes is well-established. Less is known about how exposure to violence in the school context, i.e., by teachers and by peers, affects academic functioning. Moreover, the role of children's mental health problems in this link has hardly been examined. OBJECTIVES: We examined direct and indirect associations between children's experiences of violence by teachers and peers and children's mental health and school functioning while controlling for children's experiences of parental violence. PARTICIPANTS: Using a multistage random sampling approach, we obtained a representative sample of 914 students (50.5 % girls, Mage = 12.58 years) from 12 primary schools in Tanzania. METHODS: In structured interviews, students' experiences of violence and mental health problems were assessed. Students' academic performance and absenteeism were documented using school records. Associations were examined using structural equation modeling. RESULTS: Experiences of more teacher and peer violence were each significantly associated with higher externalizing problems (teachers: ß = 0.27 [95 %-CI: 0.12, 0.47]; peers: ß = 0.17, [95 %-CI: 0.07, 0.32]). Higher externalizing problems were significantly associated with poorer academic performance (ß = -0.13, [95 %-CI: -0.23, -0.02]), implying significant indirect associations between students' experiences of teacher violence (ß = -0.04, [95 %-CI: -0.08, -0.01]) and peer violence (ß = -0.02, [95 %-CI: -0.05, -0.01]) and their academic performance via externalizing problems. CONCLUSION: Exposure to violence at school may impair children's academic performance indirectly by increasing attention and behaviour problems. Further investigations in longitudinal studies and implementation of interventions to reduce violence in schools are indicated.