Studies on the interplay between mental health and school achievement among students in the first years of primary school in Sweden

The general objective of this thesis was to increase the knowledge of how mental health and school performance are associated and how interventions may be designed and implemented to enhance the two. The data used in the four quantitative studies on which this thesis is based were derived from two age cohorts of students attending 14 elementary schools in two cities in the southern part of Sweden. The data were collected in the month of January in 2010, 2011, and 2012, thus allowing the individual students’ development to be tracked over a total of 2 years. The data were obtained using the Strengths and Difficulties Questionnaire (SDQ), a health questionnaire, standardized tests, and measurement of physiological variables. Seven of the fourteen schools were part of an intervention called UTSIKTER, that aimed to improve academic test results, while the remaining seven schools served as comparison schools. The students were in grades 1 and 2 at the first data collection and in grades 3 and 4 at the last data collection. Three of the quantitative studies involved cross-sectional designs and one a longitudinal design. The data were analyzed using exploratory factor analysis, logistic, linear, and multilevel regression analyses, Cronbach’s alpha, sensitivity/specificity analysis, and effect modification. The data of the qualitative study, namely, study V, were obtained by holding focus group discussions with the teachers working at the intervention schools; these data were analyzed using a grounded theory approach. Mental health was independently associated with reading comprehension, writing composition, and mathematics test results. Associations were also found between socioeconomic factors and school performance; students who came from families with a low educational level were particularly sensitive to the effects of poor mental health on their school performance. Mental health in the first and second grades predicted reading comprehension outcomes two years later. The school class and school levels together explained 16–23% of the students’ variance in school achievement. The intervention schools showed a significantly greater improvement in reading comprehension in grades 3 and 4 relative to in grades 1 and 2 than the comparison schools; this was possibly mediated by the students’ improved mental health status. The intervention and comparison schools did not differ significantly in terms of mathematics results. Teacher SDQ assessments, but not parent assessments, showed an adequate construct validity that did not seem to be affected by student socioeconomic background. Parent SDQ assessments were, however, influenced by socio-economic factors. Both teacher and parent SDQ assessments had acceptable internal consistency. The qualitative study on the teachers’ experience of the intervention process revealed important factors that promoted teacher engagement described by the core category “Getting one’s bearings on a maiden voyage”. The associations between mental health, school performance, and socio-economic status suggest that societal inequity is already present and exerting deleterious effects in the early school years. The school intervention UTSIKTER showed a potential in terms of improving school performance, possibly by ameliorating mental health. The teacher’s involvement in the implementation process seemed to influence intervention outcomes and should thus be carefully considered when designing school intervention programs. The associations between mental health and school performance were especially pronounced for children from families with low socio-economic status, which suggests that school interventions that aim to improve mental health as well as school performance may improve health equity as well as equity in general.