News Release

Prevention of mental health problems among schoolchildren could avoid grade repetition and dropout

A study involved 2,511 families with children aged 6-14. The findings show that externalizing disorders such as attention deficit and hyperactivity have more adverse effects than conditions associated with anxiety and fear.

Peer-Reviewed Publication

Fundação de Amparo à Pesquisa do Estado de São Paulo

At least ten out of every 100 girls older than the appropriate age for their school grade could have accompanied their age group if mental health problems were prevented or treated, especially externalizing disorders (problematic behavior relating to poor impulse control, such as attention deficit and hyperactivity, aggression, impulsivity, and rule-breaking). Among children in the Brazilian public education system, data on the incidence of mental health problems are also reflected by grade repetition: five out of every 100 girls would not have been failed. For boys, the age-grade distortion would have been avoided in 5.3% of cases, and grade repetition in 4.8%.

These findings come from an innovative survey led by a group of Brazilian and British scientists and reported in an article published in the journal Epidemiology and Psychiatric Sciences. The authors set out to estimate the weight and impact of various kinds of psychiatric disorders on educational outcomes. 

Using data for 2014, they concluded that externalizing disorders had broader and more robust negative effects on educational attainment than disorders associated with anxiety and fear. A breakdown by gender showed that they were particularly harmful to girls, resulting in lower levels of literacy and more frequent bullying.

At least 11 out of every 100 reports of physical or psychological bullying by girls in Brazilian schools could have been avoided if externalizing disorders had been prevented or treated. For boys, phobias and depression entailed higher school dropout rates.
“In epidemiological terms, boys generally have more externalizing disorders, with case numbers reaching double those of girls. In terms of educational outcomes, however, we found that the risk is greater for girls.

One of the hypotheses that could explain this finding is a social stigma, since aggressive or oppositional behavior is not expected from girls, and they may suffer more and perform less well at school. The same is true of depression in the case of boys. Society assumes they don’t cry or express feelings,” Mauricio Scopel Hoffmann, first author of the article, told Agência FAPESP. Hoffmann is a professor in the Department of Neuropsychiatry at the Federal University of Santa Maria (UFSM) in Rio Grande do Sul (Brazil).

The study was part of Hoffmann’s postdoctoral research and was supported by FAPESP (grants 14/50917-0 and 08/57896-8). Hoffmann was supported by a Newton International Fellowship awarded by the Academy of Medical Sciences through the UK Government's Newton Fund Program. The Newton Fund also supported Sara Evans-Lacko, last author of the article. Both were then research fellows at the LSE’s Care Policy and Evaluation Center in London (2019-20).

The data was obtained from the Brazilian High-Risk Cohort Study for Childhood Psychiatric Disorders (BHRC[KM1] ), a large school-based survey that has followed over 1,000 children since 2010.

In their discussion of the 2014 data, the researchers contextualized their findings from a populational perspective and, while warning that their estimates were probably conservative, concluded that at that time at least 591,000 schoolchildren could have been in the right grade for their age if psychiatric disorders had been prevented or treated. Repetition could have been avoided for some 196,000 on the same basis.

According to Hoffmann, the situation is similar seven years later, evidencing the importance of prevention and treatment of mental problems if educational results are to be improved. In 2014, 49.8 million children were enrolled in the first nine grades at 188,700 public and private schools. In 2020, these numbers had fallen to 47.3 million and 179,500 respectively.

Longitudinal study

Considered one of the most ambitious childhood mental health surveys ever conducted in Brazil, the BHRC, also known as Project Connection – Minds of the Future, is part of the National Institute of Developmental Psychiatry (INPD). 

INPD is supported by FAPESP and the National Council for Scientific and Technological Development (CNPq). Its principal investigator is Eurípedes Constantino Miguel Filho, a professor in the Department of Psychiatry at the University of São Paulo’s Medical School (FM-USP). More than 80 university professors and researchers affiliated with 22 institutions are involved in its activities.

For this latest study, the researchers analyzed baseline (2010-11) data and three-year follow-up (2013-14) BHRC data, considering a screening stage and an assessment stage. Propensity score weights (PSWs) were used to balance participants with and without psychiatric conditions for baseline characteristics.

In the screening stage, all parents at 22 state-funded schools in Porto Alegre and 35 in São Paulo were invited to participate on compulsory school registration days in 2010. A total of 2,511 families were selected for the full household assessment, including children aged 6-14.

Psychiatric disorders were grouped into three broad categories: fear-related conditions, including panic, separation and social anxiety disorder, specific phobia and agoraphobia; distress-related conditions, including anxiety disorder, depressive disorders, bipolar disorder, obsessive-compulsive disorder, and post-traumatic stress disorder; and externalizing conditions, including attention deficit, hyperactivity, and oppositional-defiant conditions.

The researchers used the Development and Wellbeing Assessment (DAWBA), a package of interviews, questionnaires, and rating techniques, and calculated population-attributable risk percentages to estimate the proportion of adverse educational outcomes that could be attributed to psychiatric conditions. The analyses were conducted separately for males and females. 

“One of the aims was to find out whether undesired school events could be avoided if mental health problems were treated, and to what extent,” Hoffmann said. “We obtained a very clear practical result, since outcomes such as age-grade distortion, repetition, dropout, and bullying are linked to this question,” Hoffmann said. 

Besides the adverse impacts on education, particularly for girls, mental health problems can limit future socio-economic opportunities, leading to an increase in gender inequity in the labor market, for example.

Estimates suggest one in four people may develop mental health problems during their lifetime. Psychiatric disorders are among the leading causes of incapacitation in the 14-50 age group. According to projections by the World Health Organization (WHO), the cost of these cases to the world economy could reach USD 6 trillion in 2030.

“Correct diagnosis is the first step,” Hoffmann said. “This would help reduce some of the problems faced by schools. Policies that encourage detection of psychiatric disorders in childhood and adolescence, permitting early intervention, could have profound consequences for educational attainment throughout the population.”

The school census carried out in 2020 by Brazil’s Ministry of Education pointed to age-grade distortion in 22.7% of the children enrolled in the final grades of primary education, and 26.2% of those in secondary education. The proportion increased from the third year of primary schooling onward, peaking in the seventh year of primary school and the first year of secondary school.

The distortion results from the number of children who are failed and/or drop out in a given school year, among other factors. The process will be hard to reverse. Children who fall behind in the early years of their basic education tend to remain too old for their grade until adolescence, and often drop out before they graduate from high school as a result.

Indeed, Brazil had the fourth-highest percentage of schoolchildren who repeated a grade at least once during their formal education among 79 countries analyzed in a report published by the Organization for Economic Cooperation and Development (OECD). In the 15-year-old age group, 34% repeated a grade at least once. Ahead of Brazil were Morocco with 49.3%, Colombia with 40.8%, and Lebanon with 34.5%. The report was published in 2020 and is based on indicators from the OECD’s Program for International Student Assessment (PISA).

According to Hoffmann, who is a medical doctor, education and health should partner to strengthen prevention as one of the ways to reduce the adverse effects of psychiatric disorders on schooling. “Attention deficit and hyperactivity disorder [ADHD] is an example. We know only 20% of these cases are detected in Brazil. If we could lift that to 30%, some 8,000 grade repetitions could be avoided each year,” he said.

Teachers could usefully help. The Brazilian research group has created a handbook to help teachers deal with student mental health problems, stressing the importance of their role as mediators to avoid stigma.


Mental health has come to the fore during the COVID-19 pandemic, and new research has focused on the effects on children and adolescents of social distancing, confinement, and remote schooling. According to Hoffmann, a group led by Patrícia Pinheiro Bado, a researcher in the field of neuroscience and human behavior, is investigating the links between engagement in online learning and child mental health.

Recently published British research presents evidence that children, adults, and seniors with prior mental health problems have suffered more during the pandemic owing to job loss, illness, and emotional hardship.

In Brazil, where schools remained closed for a long period because of COVID-19, the United Nations Children’s Fund (UNICEF) estimated that 1.5 million children aged 6-17 were out of school and not taking online classes in November 2020, while another 3.7 million attended school but no school activities were available and they were unable to continue learning at home.


About São Paulo Research Foundation (FAPESP)

The São Paulo Research Foundation (FAPESP) is a public institution with the mission of supporting scientific research in all fields of knowledge by awarding scholarships, fellowships and grants to investigators linked with higher education and research institutions in the State of São Paulo, Brazil. FAPESP is aware that the very best research can only be done by working with the best researchers internationally. Therefore, it has established partnerships with funding agencies, higher education, private companies, and research organizations in other countries known for the quality of their research and has been encouraging scientists funded by its grants to further develop their international collaboration. You can learn more about FAPESP at and visit FAPESP news agency at to keep updated with the latest scientific breakthroughs FAPESP helps achieve through its many programs, awards and research centers. You may also subscribe to FAPESP news agency at

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