A randomized study of parent- versus child-directed intervention for Dutch toddlers with DLD.

BACKGROUND: Indirect speech and language therapy, such as parent-implemented intervention, has been shown to be an effective approach for young children with speech and language disorders. However, relatively few studies have compared outcomes of parent-directed therapy with child-directed intervention, that is, individual therapy of a child delivered by a speech and language therapist (SLT). Although speech and language therapists (SLTs) regard parental engagement as imperative for successful intervention, currently they predominantly use child-directed intervention. AIM: To evaluate the effect of parent- versus child-directed speech-language therapy embedded in usual care intervention for young children with developmental language disorder (DLD). METHODS & PROCEDURES: In a randomized trial, forty-six 3-year-old monolingual children with DLD were assigned to parent-directed intervention or child-directed intervention groups. In addition, all children received usual care in special-language daycare centres. Outcomes included children's language development and functional communication, parents' language output, parents' perceptions and their self-efficacy. These were assessed at three time intervals, that is, at baseline, immediately after 6 months of treatment, and 1 year after baseline. The parent-directed intervention consisted of twelve 50-min sessions every 2 weeks with parent and child, consisting of parental training with immediate feedback by (SLTs. Children in the child-directed intervention group received individual speech-language therapy in weekly 30-min sessions for 6 months. OUTCOMES & RESULTS: Intervention in both groups was equally effective. All children improved significantly in receptive and expressive language measures as well as in functional communication at all intervals. All parents used significantly more language support strategies and were less concerned about their child's participation in communication. Parents in the parent-directed intervention group reported increased self-efficacy in stimulating their child's language development. In contrast, parents in the child-directed intervention group reported a decrease in self-efficacy. Though modest, these group differences were significant in both the short and long terms. Both parents and SLTs were positive about the parent-directed intervention. CONCLUSIONS & IMPLICATIONS: The effects of parent- and child-directed intervention for young children with DLD are similar. The parent-directed intervention adds to treatment options for parents as well as for SLTs and creates choices for shared decision-making. WHAT THIS PAPER ADDS: What is already known on the subject Language therapy for young children with DLD comprises various delivery models. Two of these are child- and parent-directed therapy by SLTs. Compared with no treatment, both delivery models are effective, but it is unclear if one of these results in better language outcomes than the other. SLTs value child-directed intervention more highly than indirect approaches where treatment is delivered by others. This study aims to compare the relative effectiveness of parent-directed intervention with child-directed intervention, both parts of multi-component usual care intervention. What this paper adds to existing knowledge This randomized trial indicates that a parent-directed intervention model is as effective as child-directed intervention by SLTs for children's language development and functional communication. Parents' use of language support strategies was also similar in both intervention models, in the short and long terms. Like in child-directed therapy, parent-directed intervention reduces parents' concerns. Contrary to child-directed treatment, parent-directed intervention increases parents' self-efficacy, that is, supporting their child's language development. What are the potential or actual clinical implications of this work? Though SLTs predominantly choose a child-directed intervention model, the study results show that they can consider parent-directed approaches too. There are no significant differences in children's language outcomes as a function of parent- or child-directed intervention. Furthermore, parents and SLTs were positive about the parent-directed intervention program and the SLTs evaluated it as valuable and feasible.

Effects in language development of young children with language delay during early intervention.

INTRODUCTION: In the Netherlands, early language intervention is offered to young children with Language Delay (LD). The intervention combines groupwise language intervention, individual speech and language therapy and parent-implemented language intervention. This study tests the hypothesis that children with LD show progress in their receptive and expressive language during intervention. Differences in language progress between age groups (< 36 months and ≥ 36 months at intervention start) were expected in favour of the younger group, which might be due to an earlier intervention start, a longer treatment duration or the potential presence of late talkers. METHODS: The study included 183 children with LD (45 children < 3 years of age at intervention start; mean age 32 months, 138 children ≥ 3 years; mean age 40 months). Receptive and expressive language was assessed with norm-referenced tests at intervention start and ending using Routine Outcome Monitoring. A repeated measures MANOVA was carried out to examine language progress and to compare the age groups on receptive syntax, receptive vocabulary, expressive syntax and expressive vocabulary. The Reliable Change Index was used to study individual progress. RESULTS: On average, children in both age groups showed significant improvement in all four language domains. The younger children showed more language progress than the older children in all four domains. When examining individual progress, most of the children displayed reliable improvement for expressive vocabulary. Most children developed in the same pace as their typically developing peers for receptive syntax, receptive vocabulary, and expressive syntax. CONCLUSIONS: Children stabilized or even improved language proficiency during the intervention, indicating that the language gap between these children and typically developing children did not widen further. Younger children displayed more language progress than older children in all four domains, but it is unclear what might explain this difference.

Short report: Longitudinal study on emotion understanding in children with and without developmental language disorder.

BACKGROUND: Children with Developmental Language Disorder (DLD) have difficult access to social interactions, which could in turn limit their opportunities to learn about others' emotions. AIMS: This study aimed to investigate the developmental trajectories of emotion understanding in young children with and without DLD. METHODS AND PROCEDURES: 95 DLD children and 149 non-DLD children were tested twice, with an approximately two-year interval (Mage = 3.58 years at Time 1), on three indices for emotion understanding (discrimination, identification, and attribution in emotion-evoking situations). OUTCOMES AND RESULTS: At Time 2, DLD children fell behind their non-DLD peers on the non-verbal task for emotion discrimination, while catching up on the verbal tasks for emotion identification and attribution. The two groups developed most of these skills with a similar improvement over time, but DLD children showed a greater increase in positive emotion identification and attribution with age than non-DLD children. CONCLUSIONS AND IMPLICATIONS: The findings showed the potential of DLD children to understand others' emotions in verbal tasks to a similar extent as their non-DLD peers. However, DLD children may still face difficulties understanding more implicit emotional messages in real-life situations, and longitudinal follow-ups are required to reveal these challenges.

Language development and behaviour problems in toddlers indicated to have a developmental language disorder.

BACKGROUND: There is empirical evidence that a developmental language disorder (DLD) in early childhood leads to behaviour problems. However, it is still not clear how changes in language proficiency in these children influence the presence of behaviour problems. AIMS: The aim of this study is to examine if changes in language proficiency are related to changes in behaviour problems in toddlers indicated to have DLD. METHODS & PROCEDURES: This study included 185 toddlers indicated to have DLD (mean age 38 months at pretest). Scores on receptive and expressive language domains and internalizing and externalizing behaviour were gathered on Wave 1 and Wave 2 using Routine Outcome Monitoring. The Reliable Change Index was used to categorize children into two groups: children improving in receptive and expressive language domains and children not improving. OUTCOMES & RESULTS: For receptive syntax, receptive vocabulary and expressive syntax, 30% or less of the children improved. Only for expressive vocabulary, most children improved (63%). Behaviour problems were present in 17% (internalizing) and 23% (externalizing) of the children. Changes in language proficiency did not lead to changes in internalizing or externalizing behaviour problems, not for the total sample, nor for children displaying behaviour problems at Wave 1. CONCLUSIONS & IMPLICATIONS: Professionals working with toddlers indicated to have DLD need to be aware of the co-occurrence of language problems and behaviour problems, and have to realize that behaviour problems might not immediately decrease when language proficiency improves. If behaviour problems are present in toddlers indicated to have DLD, interventions should not only focus on language, but also on behaviour problems. WHAT THIS PAPER ADDS: What is already known on the subject There is empirical evidence that a developmental language disorder (DLD) in early childhood leads to behaviour problems. However, it is still not clear how changes in language proficiency in children with DLD influence the presence of behaviour problems. What this paper adds to existing knowledge This study addresses if a change in language proficiency is related to changes in child behaviour problems in toddlers indicated to have DLD. The results of our study showed that most of the children did not show a positive reliable change in receptive syntax, receptive vocabulary and expressive syntax at this young age, but most of the children did in expressive vocabulary. Furthermore, changes in language proficiency did not lead to changes in the presence of internalizing or externalizing behaviour problems. What are the potential or actual clinical implications of this work? Therefore, professionals working with toddlers indicated to have DLD should be aware of the co-occurrence of language problems and behaviour problems, and have to realize that behaviour problems might not decrease as a result of improved language proficiency. If behaviour problems are present and need to be treated, other interventions, apart from the language intervention, might be necessary.

The Developmental Trajectory of Empathy and Its Association with Early Symptoms of Psychopathology in Children with and without Hearing Loss.

Empathy enables people to share, understand, and show concern for others' emotions. However, this capacity may be more difficult to acquire for children with hearing loss, due to limited social access, and the effect of hearing on empathic maturation has been unexplored. This four-wave longitudinal study investigated the development of empathy in children with and without hearing loss, and how this development is associated with early symptoms of psychopathology. Seventy-one children with hearing loss and cochlear implants (CI), and 272 typically-hearing (TH) children, participated (aged 1-5 years at Time 1). Parents rated their children's empathic skills (affective empathy, attention to others' emotions, prosocial actions, and emotion acknowledgment) and psychopathological symptoms (internalizing and externalizing behaviors). Children with CI and TH children were rated similarly on most of the empathic skills. Yet, fewer prosocial actions were reported in children with CI than in TH children. In both groups, affective empathy decreased with age, while prosocial actions and emotion acknowledgment increased with age and stabilized when children entered primary schools. Attention to emotions increased with age in children with CI, yet remained stable in TH children. Moreover, higher levels of affective empathy, lower levels of emotion acknowledgment, and a larger increase in attention to emotions over time were associated with more psychopathological symptoms in both groups. These findings highlight the importance of social access from which children with CI can learn to process others' emotions more adaptively. Notably, interventions for psychopathology that tackle empathic responses may be beneficial for both groups, alike.

Association of language, behavior, and parental stress in young children with a language disorder.

BACKGROUND: Several studies show that language problems, child behavior problems, and parental stress can co-occur in children. Still, little is known about how these domains are related in toddlers with a language disorder (LD). AIMS: This study examined relations between language problems, child behaviour problems, and parental stress in toddlers with LD and if these relations differ for children with different types of LD. METHOD: Data of 185 children with LD (mean age 38 months) were collected using Routine Outcome Monitoring. Children were divided into two groups: presence of receptive and expressive problems (REP) and expressive problems only (EP). Relations were analyzed using Structural Equation Modeling. RESULTS: A better receptive language was associated with less teacher-reported internalizing and externalizing problems. A better expressive vocabulary was associated with more parent-reported internalizing problems and more teacher-reported externalizing problems. No relation was found between language and parental stress. Associations between language, behavior, and parental stress did not differ for children with REP or children with EP. CONCLUSIONS: Our study shows that when specific language domains are examined, the pattern of associations between language and behavior becomes more complex, because relations exist between specific language domains and behavior, but not between all of them.

Happy faces, sad faces: Emotion understanding in toddlers and preschoolers with language impairments.

BACKGROUND: The capacity for emotion recognition and understanding is crucial for daily social functioning. We examined to what extent this capacity is impaired in young children with a Language Impairment (LI). In typical development, children learn to recognize emotions in faces and situations through social experiences and social learning. Children with LI have less access to these experiences and are therefore expected to fall behind their peers without LI. METHOD: In this study, 89 preschool children with LI and 202 children without LI (mean age 3 years and 10 months in both groups) were tested on three indices for facial emotion recognition (discrimination, identification, and attribution in emotion evoking situations). Parents reported on their children's emotion vocabulary and ability to talk about their own emotions. RESULTS: Preschoolers with and without LI performed similarly on the non-verbal task for emotion discrimination. Children with LI fell behind their peers without LI on both other tasks for emotion recognition that involved labelling the four basic emotions (happy, sad, angry, fear). The outcomes of these two tasks were also related to children's level of emotion language. IMPLICATIONS: These outcomes emphasize the importance of 'emotion talk' at the youngest age possible for children with LI.

Children With Cochlear Implants and Their Parents: Relations Between Parenting Style and Children's Social-Emotional Functioning.

OBJECTIVES: Parenting a child who has a severe or profound hearing loss can be challenging and at times stressful, and might cause parents to use more adverse parenting styles compared with parents of hearing children. Parenting styles are known to impact children's social-emotional development. Children with a severe to profound hearing loss may be more reliant on their parents in terms of their social-emotional development when compared with their hearing peers who typically have greater opportunities to interact with and learn from others outside their family environment. Identifying the impact which parenting styles pertain on the social-emotional development of children who have cochlear implants (CIs) could help advance these children's well-being. Therefore, the authors compared parenting styles of parents with hearing children and of parents with children who have a CI, and examined the relations between parenting styles and two key aspects of children's social-emotional functioning: emotion regulation and empathy. DESIGN: Ninety-two hearing parents and their children (aged 1 to 5 years old), who were either hearing (n = 46) or had a CI (n = 46), participated in this cross-sectional study. Parents completed questionnaires concerning their parenting styles (i.e., positive, negative and uninvolved), and regarding the extent to which their children expressed negative emotions (i.e., anger and sadness) and empathy. Furthermore, an emotion-regulation task measuring negative emotionality was administered to the children. RESULTS: No differences in reported parenting styles were observed between parents of hearing children and parents of children with a CI. In addition, negative and uninvolved parenting styles were related to higher levels of negative emotionality in both groups of children. No relation was found between positive parenting and children's social-emotional functioning. Hearing status did not moderate these relationships. Language mediated the relationship between parenting styles and children's social-emotional functioning. CONCLUSIONS: Children's hearing status did not impact parenting styles. This may be a result of the support that parents of children with a CI receive during their enrollment in the rehabilitation program preceding and after implantation. Rehabilitation programs should dedicate more attention to informing parents about the impact of parenting behaviors on children's social-emotional functioning. Offering parenting courses as part of the program could promote children's well-being. Future longitudinal research should address the directionality of the relations between parenting styles and children's social-emotional functioning.

Preliminary findings on associations between moral emotions and social behavior in young children with normal hearing and with cochlear implants.

Moral emotions such as shame, guilt and pride are the result of an evaluation of the own behavior as (morally) right or wrong. The capacity to experience moral emotions is thought to be an important driving force behind socially appropriate behavior. The relationship between moral emotions and social behavior in young children has not been studied extensively in normally hearing (NH) children, let alone in those with a hearing impairment. This study compared young children with hearing impairments who have a cochlear implant (CI) to NH peers regarding the extent to which they display moral emotions, and how this relates to their social functioning and language skills. Responses of 184 NH children and 60 children with CI (14-61 months old) to shame-/guilt- and pride-inducing events were observed. Parents reported on their children's social competence and externalizing behavior, and experimenters observed children's cooperative behavior. To examine the role of communication in the development of moral emotions and social behavior, children's language skills were assessed. Results show that children with CI displayed moral emotions to a lesser degree than NH children. An association between moral emotions and social functioning was found in the NH group, but not in the CI group. General language skills were unrelated to moral emotions in the CI group, yet emotion vocabulary was related to social functioning in both groups of children. We conclude that facilitating emotion language skills has the potential to promote children's social functioning, and could contribute to a decrease in behavioral problems in children with CI specifically. Future studies should examine in greater detail which factors are associated with the development of moral emotions, particularly in children with CI. Some possible directions for future research are discussed.

Social competence and empathy in young children with cochlear implants and with normal hearing.

OBJECTIVES: To examine the levels of social competence and empathic behavior in children with cochlear implants in comparison with normal-hearing children, and to determine whether empathy predicts social competence to the same extent in both groups of children. STUDY DESIGN: Retrospective cohort study. METHODS: A total of 150 children (mean age 39 months) participated in the study; 61 with cochlear implants and 89 without hearing loss. Parent reports and observation measures were employed to measure empathy and social competence. RESULTS: Levels of empathy and social competence in children with cochlear implants and normal-hearing children were similar. Empathic behaviors were predictive of social competence in both groups alike. Emotion acknowledgment was more predictive of social competence for children with cochlear implants than for normal-hearing children. Language skills were unrelated to social competence or empathic behaviors in children with cochlear implants. CONCLUSIONS: Children with cochlear implants showed no delay concerning social competence or empathic behavior. The factors contributing to social competence, however, differed between the groups. This should be kept in mind when developing rehabilitation programs for children with cochlear implants.

Emotion understanding in deaf children with a cochlear implant.

It is still largely unknown how receiving a cochlear implant affects the emotion understanding in deaf children. We examined indices for emotion understanding and their associations with communication skills in children aged 2.5-5 years, both hearing children (n = 52) and deaf children with a cochlear implant (n = 57). 2 aspects of emotion understanding were examined: (a) emotion recognition in facial expressions and (b) emotion attribution in a situational context. On all emotion-understanding tasks, children with a cochlear implant were less proficient than children with normal hearing. In children with normal hearing, performance and language skills were positively associated. In children with cochlear implants, language was positively associated only with tasks in which a verbal demand was made on children. These findings indicate that hearing loss in children, despite a cochlear implant, affects all aspects of emotion understanding measured in this study, including their nonverbal emotion-understanding skills.

Does hearing lead to understanding? Theory of mind in toddlers and preschoolers with cochlear implants.

OBJECTIVE: Theory of Mind (ToM) refers to the ability to understand the subjectivity of people's intentions, desires, and beliefs. Research shows that ToM in deaf children is delayed, yet the few studies that examined ToM in deaf children with a cochlear implant (CI) report contradictory results. This study examined multiple aspects of ToM in early-implanted children. METHODS: 3 intention tasks were administered to 72 children with CI and 69 normal-hearing children (age, 12-60 months). Furthermore, 3 desire and belief tasks were administered to a subsample of children aged 30 months or over. RESULTS: Children with CI showed intention-understanding skills equal to normal-hearing children, but lagged behind on desire and belief understanding, even after excluding children with language delays. CONCLUSIONS: Children with CI appear to master the initial stages of ToM development, but fall behind on more advanced ToM abilities. Yet, both groups showed similar patterns of development.

Family counseling in the Netherlands for Turkish-origin parents of deaf children with a cochlear implant.

Cultural elements such as language, beliefs about health, and family context play important roles in the uptake of rehabilitation and treatment of deafness. Because of cultural issues, minority groups often do not receive optimal care. Focusing on the Netherlands, the researchers explored how the rehabilitation and counseling of deaf children of Turkish-origin parents can be improved. The most important findings were that (a) most parents initially did not believe their child was deaf and regretted later that they did not start hearing rehabilitation earlier; (b) parents had little confidence in the Dutch health care system and sought a second opinion from a medical doctor of their own national origin; (c) parents did not know how to be actively involved in the care of their deaf child. Implications for practice aimed at improving rehabilitation and counseling for these children are described.

Predicting social functioning in children with a cochlear implant and in normal-hearing children: the role of emotion regulation.

OBJECTIVE: The purpose of the present study was to compare children with a cochlear implant and normal hearing children on aspects of emotion regulation (emotion expression and coping strategies) and social functioning (social competence and externalizing behaviors) and the relation between emotion regulation and social functioning. METHODS: Participants were 69 children with cochlear implants (CI children) and 67 normal hearing children (NH children) aged 1.5-5 years. Parents answered questionnaires about their children's language skills, social functioning, and emotion regulation. Children also completed simple tasks to measure their emotion regulation abilities. RESULTS: Cochlear implant children had fewer adequate emotion regulation strategies and were less socially competent than normal hearing children. The parents of cochlear implant children did not report fewer externalizing behaviors than those of normal hearing children. While social competence in normal hearing children was strongly related to emotion regulation, cochlear implant children regulated their emotions in ways that were unrelated with social competence. On the other hand, emotion regulation explained externalizing behaviors better in cochlear implant children than in normal hearing children. While better language skills were related to higher social competence in both groups, they were related to fewer externalizing behaviors only in cochlear implant children. CONCLUSIONS: Our results indicate that cochlear implant children have less adequate emotion-regulation strategies and less social competence than normal hearing children. Since they received their implants relatively recently, they might eventually catch up with their hearing peers. Longitudinal studies should further explore the development of emotion regulation and social functioning in cochlear implant children.

Professional identification of psychosocial problems among children from ethnic minority groups: room for improvement.

OBJECTIVE: To assess the effectiveness of child health care professionals (CHP) in identifying psychosocial problems among children originating from industrialized and nonindustrialized countries and to assess whether parental concerns enhance CHP problem-identification. STUDY DESIGN: During routine well-child visits data were collected from a sample of children aged 5 to 12 years of Dutch, Moroccan, Turkish, Surinam, and Antillean origin (response: 82%). CHP reported on psychosocial problems that they identified in children. Parents completed the Child Behavior Checklist (CBCL) and a questionnaire on concerns regarding their child's psychosocial development. Interpreter services were used to support parents in filling out questionnaires. RESULTS: Elevated CBCL total and internalizing problem scores were more prevalent among children from nonindustrialized countries (10% and 17%, respectively) than among children from industrialized countries (3% and 5%, respectively). About 30% of the Turkish and Moroccan children with an elevated CBCL score were identified by CHPs compared with 60% of the children from industrialized countries. Parental concerns on their child's psychosocial well-being were related to elevated CBCL scores. Concerns were not related to CHP problem-identification. CONCLUSIONS: Better methods to support parents in disclosure of their concerns regarding the psychosocial development of their children may enhance CHP-identification of problems, especially among groups from nonindustrialized countries.

Identification and management of psychosocial problems among toddlers by preventive child health care professionals.

BACKGROUND: Objective of this study was to assess the degree to which preventive child health professionals (CHPs) identify and act upon psychosocial problems among young toddlers in the general population and to determine the concordance with parent-reported behavioural and emotional problems. Also, associations of psychosocial problems with socio-demographic factors, and (mental) health history of the toddlers were studied. METHODS: CHPs examined a national sample of children aged 14 months and interviewed their parents during the routine health assessments. Identification of and action upon psychosocial problems by CHPs were registered. The Infant-Toddler Social and Emotional Assessment (ITSEA) was completed by the parents. Data were available on 701 Dutch 14-month-old toddlers. RESULTS: In 7.6% of all toddlers, CHPs identified one or more psychosocial problems. Forty-seven percent of identified children were referred to another professional or received follow-up. Identification of psychosocial problems and subsequent action were 3-16 times more likely in children with clinical parent-reported problem behaviour according to the Dutch adapted version of the ITSEA. Also, past or current professional care for psychosocial problems was associated with the CHPs' identification or action. Associations with socio-demographic variables were weak. CONCLUSION: The CHPs frequently identify psychosocial problems in 14-month-old toddlers, but they miss many cases of parent-reported problems as measured by a clinical ITSEA score. This general population study shows substantial room for improvement in the early identification of psychosocial problems in young toddlers.

A review of similarities between domain-specific determinants of four health behaviors among adolescents.

Schools are overloaded with health promotion programs that, altogether, focus on a broad array of behavioral domains, including substance abuse, sexuality and nutrition. Although the specific content of programs varies according to the domain focus, programs usually address similar concepts: knowledge, attitudinal beliefs, social influences and skills. This apparent conceptual overlap between behaviors and programs provides opportunities for a transfer-oriented approach which will stimulate students to apply the knowledge and skills they have learned in one domain (e.g. skills for resisting tobacco use) to other domains (e.g. alcohol, sex). A requirement for such an approach is that behaviors share at least some determinants. This review addresses this issue by examining similarities between domain-specific determinants of smoking, drinking, safe sex and healthy nutrition among adolescents. Recent empirical studies and reviews were examined. The results show that the following determinants are relevant to all four behaviors: beliefs about immediate gratification and social advantages, peer norms, peer and parental modeling and refusal self-efficacy. Several other determinants have been found to relate to at least two behaviors, e.g. health risk beliefs and parental norms. These results can be used for the development of a transfer-oriented school health promotion curriculum.

Parents' concerns about children are highly prevalent but often not confirmed by child doctors and nurses.

BACKGROUND: The aim of this study was to assess the prevalence in the general population of parents' concerns about the development of their child, to identify groups at risk and to assess the association between parents' concerns and professional judgement. METHODS: We obtained cross-sectional data on a Dutch nationally representative sample of children aged 14 months, 3 3/4, 5-6 and 8-12 years within the setting of routine well-child visits provided to the entire population. A total of 4,107 participated (response rate 85.3%). Data were about concerns that parents reported by questionnaire before the visit regarding behavioural and emotional problems, developmental delay, consequences of disease and contact with peers that needed professional assistance, and about the assessment of these domains by doctors and nurses during the visit. Moreover, we obtained data on parent-reported psychosocial problems using the Infant-Toddler Social and Emotional Assessment and the Child Behavior Checklist. RESULTS: Of all parents, 49.3% reported some concerns and 8.7% reported frequent concerns, most frequently on child behaviour. Frequent concerns were most likely to refer to young children, children from labour immigrant families, with fathers of medium educational level and in low-income families. The prevalence rates of professional-assessed parenting problems were much lower than parent-reported ones. The rates of psychosocial problems were highest in the case of shared concerns, but also higher if parents expressed concerns that were not confirmed by professionals. CONCLUSION: A very large proportion of parents of young children have concerns regarding their child, but agreement on these concerns with child health professionals is relatively low.

Continuous admission to primary school and mental health problems.

BACKGROUND: Younger children in a school class have higher rates of mental health problems if admission to primary school occurs once a year. This study examines whether this relative age effect also occurs if children are admitted to school continuously throughout the year. METHODS: We assessed mental health problems based on parent-reports (using the Child Behavior Checklist, CBCL) and on professional assessments, among two Dutch national samples of in total 12,221 children aged 5-15 years (response rate: 86.9%). RESULTS: At ages 5-6, we found a higher occurrence of mental health problems in relatively young children, both for mean CBCL scores (p = 0.017) and for problems assessed by child health professionals (p < 0.0001). At ages 7-15, differences by relative age did not reach statistical significance. CONCLUSION: Continuous admission to primary school does not prevent mental health problems among young children, but may do so at older ages. Its potential for the prevention of mental problems deserves further study.