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Mental Health among Children with and without Reading Difficulties

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Title: Mental Health among Children with and without Reading Difficulties
Language: English
Authors: Miao Li (ORCID 0000-0002-6756-8122), Wei Zhao, Mengmeng Liu, Lele Zhang, Gen Li
Source: Annals of Dyslexia. 2024 74(1):27-46.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 20
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Education Level: Elementary Education
Early Childhood Education
Grade 3
Primary Education
Grade 4
Intermediate Grades
Grade 5
Middle Schools
Descriptors: Mental Health, Children, Reading Difficulties, Depression (Psychology), Anxiety Disorders, Elementary School Students, Foreign Countries, Grade 3, Grade 4, Grade 5, Intervention, Correlation
Geographic Terms: China
DOI: 10.1007/s11881-023-00296-2
ISSN: 0736-9387
1934-7243
Abstract: This study explored the relationship between mental health, i.e., depression and anxiety, and reading difficulties (RD) in Chinese elementary school children. Participants were 1535 grades 3, 4, and 5 students from three elementary schools in Xi'an, China. Children with and without RD were compared to their depression and anxiety. Additionally, children's self-ratings, parents' ratings, and teachers' ratings of depression and anxiety were compared to better understand mental health issues of Chinese children with RD. The findings showed that Chinese children with RD experienced more depression but not anxiety compared to their typically developing peers across all three grade levels. Reports from all three informants consistently reflected that children with RD experienced more depression. However, some inconsistencies were found between self-reported levels of depression and anxiety and the observations made by parents and teachers. Children reported experiencing more depression than their parents and teachers observed but less anxiety than their parents reported. This study emphasizes the importance of understanding the links between RD and mental health and the need for appropriate intervention programs to help children with RD cope with the mental health challenges.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1411004
Database: ERIC
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  Value: <anid>AN0175279629;bm501apr.24;2024Feb08.04:55;v2.2.500</anid> <title id="AN0175279629-1">Mental health among children with and without reading difficulties </title> <p>This study explored the relationship between mental health, i.e., depression and anxiety, and reading difficulties (RD) in Chinese elementary school children. Participants were 1535 grades 3, 4, and 5 students from three elementary schools in Xi'an, China. Children with and without RD were compared to their depression and anxiety. Additionally, children's self-ratings, parents' ratings, and teachers' ratings of depression and anxiety were compared to better understand mental health issues of Chinese children with RD. The findings showed that Chinese children with RD experienced more depression but not anxiety compared to their typically developing peers across all three grade levels. Reports from all three informants consistently reflected that children with RD experienced more depression. However, some inconsistencies were found between self-reported levels of depression and anxiety and the observations made by parents and teachers. Children reported experiencing more depression than their parents and teachers observed but less anxiety than their parents reported. This study emphasizes the importance of understanding the links between RD and mental health and the need for appropriate intervention programs to help children with RD cope with the mental health challenges.</p> <p>Keywords: Anxiety; Chinese children; Depression; Mental health; Reading difficulties</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <p>It is estimated that 5% to 10% of school-aged children have reading difficulties (RD) despite adequate cognitive abilities and classroom instruction (Ramus, [<reflink idref="bib59" id="ref1">59</reflink>]). This percentage has also been observed among Chinese children (Chan et al., [<reflink idref="bib9" id="ref2">9</reflink>]; Sun et al., [<reflink idref="bib66" id="ref3">66</reflink>]). Children with RD are at a higher risk for mental health problems compared to their typically developing peers (Boyes et al., [<reflink idref="bib5" id="ref4">5</reflink>]; Francis et al., [<reflink idref="bib20" id="ref5">20</reflink>]; Wilmot et al., [<reflink idref="bib77" id="ref6">77</reflink>]). However, limited research has been conducted comparing the mental health of Chinese children with RD to those without RD. Depression and anxiety are considered the two most common mental health disorders (Kessler et al., [<reflink idref="bib35" id="ref7">35</reflink>]). In a systematic review and meta-analysis of the prevalence of mental health disorders for Chinese children and adolescents, Chai et al. ([<reflink idref="bib8" id="ref8">8</reflink>]) reported that 22% and 25% of Chinese children and adolescents experienced depression and anxiety problems, respectively. The large number of Chinese children and adolescents with mental health problems deserves our attention and support.</p> <p>This study aimed to compare the depression and anxiety levels of Chinese children with reading disabilities (RD) to those of typically developing peers (TD) across different age groups. Additionally, the study compares self-ratings, parents' ratings, and teachers' ratings of depression and anxiety to provide a better understanding of the mental health issues faced by Chinese children with RD. This information can help develop better tools for diagnosing mental health problems for Chinese children with RD who are a vulnerable group and likely to experience more mental health problems. Furthermore, promoting understanding about the links between RD and mental health is crucial to reducing stigmatization and increasing access to mental health services for those in need. By increasing the understanding of these issues, we hope that children with RD will receive the support they need to overcome their challenges and are not overlooked or dismissed.</p> <hd id="AN0175279629-2">Mental health and reading difficulties</hd> <p>Reading difficulties (RD) are characterized by poor reading performance despite normal intelligence and adequate instruction (Ramus, [<reflink idref="bib59" id="ref9">59</reflink>]). It is the most common learning difficulty in school settings. Children with RD have been shown to exhibit a higher risk for mental health disorders, such as depression and anxiety (Francis et al., [<reflink idref="bib20" id="ref10">20</reflink>]; Georgiou & Parrila, [<reflink idref="bib22" id="ref11">22</reflink>]; Goldston et al., [<reflink idref="bib24" id="ref12">24</reflink>]; Heiervang et al., [<reflink idref="bib27" id="ref13">27</reflink>]; Ihbour et al., [<reflink idref="bib32" id="ref14">32</reflink>]; Maughan & Carroll, [<reflink idref="bib44" id="ref15">44</reflink>]; McArthur et al., [<reflink idref="bib46" id="ref16">46</reflink>]; Mugnaini et al., [<reflink idref="bib51" id="ref17">51</reflink>]; Nelson & Harwood, [<reflink idref="bib53" id="ref18">53</reflink>]). Depression is characterized by sad feelings, negative thinking, lack of interest and energy in activities, poor sleep, and changes in appetite and weight (American Psychiatric Association, [<reflink idref="bib1" id="ref19">1</reflink>]). Anxiety is characterized by worry, avoidance, fear, and distress about possible negative outcomes of upcoming events (American Psychiatric Association, [<reflink idref="bib1" id="ref20">1</reflink>]).</p> <p>Maughan and Carroll ([<reflink idref="bib44" id="ref21">44</reflink>]) found in a narrative review study that poor readers experienced a higher level of anxiety than TD peers. Another narrative review by Mugnaini et al. ([<reflink idref="bib51" id="ref22">51</reflink>]) found that poor readers of all ages are at risk for depression and anxiety. Moreover, poor readers with attention problems are at a higher risk for depression and anxiety compared to poor readers without attention problems. In a meta-analysis, Nelson and Harwood ([<reflink idref="bib53" id="ref23">53</reflink>]) revealed that children with RD experience greater problems with anxiety than TD children. In another meta-analysis, Francis et al. ([<reflink idref="bib20" id="ref24">20</reflink>]) found that poor readers and TD readers differed significantly in measures of depression (<emph>d</emph> = 0.41) and anxiety (<emph>d</emph> = 0.23), respectively. Together, the existing studies suggest a moderate association between mental health and poor reading, with children with RD being at an increased risk for experiencing mental health problems.</p> <p>Research has shown that several factors account for mental health problems in children with RD, including low self-esteem, low self-concept, difficulties with regulating emotions, and social skills difficulties (Claessen et al., [<reflink idref="bib11" id="ref25">11</reflink>]; McArthur et al., [<reflink idref="bib45" id="ref26">45</reflink>]; Wilmot et al., [<reflink idref="bib77" id="ref27">77</reflink>]). For instance, the frustration and shame they may feel when they struggle to read can have a profound impact on their self-esteem and confidence. Furthermore, they may face negative reactions from peers and teachers, which can exacerbate their feelings of isolation and inadequacy (Leitão et al., [<reflink idref="bib39" id="ref28">39</reflink>]). Additionally, experiencing peer problems and being bullied have also been linked to mental health problems in children with RD (see Boyes et al., [<reflink idref="bib4" id="ref29">4</reflink>], [<reflink idref="bib5" id="ref30">5</reflink>]). A better understanding of the factors associated with mental health and RD can help develop effective interventions to support children with RD who may be struggling with mental health concerns.</p> <p>Although the majority of studies support the view that children with RD exhibit higher rates of depression and anxiety compared to their chronological-age controls, mixed findings have also been reported. For example, Miller et al. ([<reflink idref="bib50" id="ref31">50</reflink>]) administered self-rating, parent-rating, and teacher-rating of depression and anxiety protocols to a group of 6–16-year-old RD children with their siblings and their TD peers. They found that children with RD were not at an elevated risk for depression and anxiety compared to their TD peers. Mattek and Wierzbicki ([<reflink idref="bib43" id="ref32">43</reflink>]) also reported that adult students with RD were not found to have more depression than their TD controls. Similarly, Riddick et al. ([<reflink idref="bib60" id="ref33">60</reflink>]) did not find a significant difference between adult RD students and their typical controls on anxiety. The impact of the mental health, specifically depression and anxiety, on children with RD is variable, and not all children with RD experience significant emotional challenges. Some children naturally develop effective coping strategies to manage stress and frustration, which can mitigate the emotional impact of RD (Miller et al., [<reflink idref="bib50" id="ref34">50</reflink>]; Mattek & Wierzbicki, [<reflink idref="bib43" id="ref35">43</reflink>]). A nurturing and supportive environment at home and school can buffer the impact of RD on a child's emotional well-being (Riddick et al., [<reflink idref="bib60" id="ref36">60</reflink>]). Positive relationships with family members, teachers, and peers contribute to a sense of security and reduce the risk of depression and anxiety. However, due to inconsistencies between studies examining mental health in individuals with RD, more research is needed to investigate the relationship between mental health and RD.</p> <hd id="AN0175279629-3">Attention</hd> <p>Attention is highly associated with RD (Willcutt et al., [<reflink idref="bib76" id="ref37">76</reflink>]). Studies report that 18–45% of individuals with RD also have attention deficit and hyperactivity disorder (ADHD) (Sexton et al., [<reflink idref="bib64" id="ref38">64</reflink>]; Willcutt & Pennington, [<reflink idref="bib75" id="ref39">75</reflink>]). Inattention refers to difficulty in maintaining attention, while hyperactivity refers to impulsivity and difficulty in regulating attention (American Psychiatric Association, [<reflink idref="bib1" id="ref40">1</reflink>]). Research shows that children with RD are not only at elevated risk of depression and anxiety but also have more attention problems (Arnold et al., [<reflink idref="bib3" id="ref41">3</reflink>]; Carroll et al., [<reflink idref="bib7" id="ref42">7</reflink>]; Pierce et al., [<reflink idref="bib58" id="ref43">58</reflink>]). For example, Carroll et al. ([<reflink idref="bib7" id="ref44">7</reflink>]) investigated psychiatric disorders, including depression and anxiety, in a large-scale sample of British children with RD aged 9 to 15 years. They found that RD was significantly associated with anxiety via inattention. However, Arnold et al. ([<reflink idref="bib3" id="ref45">3</reflink>]) found that children with RD reported higher levels of depression and anxiety than typically developing children after controlling for attention. Children with RD having attention problems are also found to be at higher risk for depression and anxiety than children with RD but without attention problems (Mugnaini et al., [<reflink idref="bib51" id="ref46">51</reflink>]).</p> <p>It is believed that poor mental health, such as depression and anxiety, may consume processing capacity, thus reducing the amount of attention and ability to complete complex reading tasks (Eysenck et al., [<reflink idref="bib19" id="ref47">19</reflink>]). Therefore, since there is an association between attention, mental health, and poor reading, attention should be considered or controlled when interpreting the relationship between mental health and poor reading.</p> <hd id="AN0175279629-4">Gender</hd> <p>A growing body of research has examined the relationship between mental health and poor reading and has suggested that gender might play a role in this relationship. Studies have consistently shown that females are more vulnerable to negative emotional disorders than males (Nolen-Hoeksema et al., [<reflink idref="bib54" id="ref48">54</reflink>]; Wang, [<reflink idref="bib72" id="ref49">72</reflink>]). This gender difference also extends to reading abilities. Females with RD were found to show more symptoms of anxiety than males with RD (Hoy et al., [<reflink idref="bib29" id="ref50">29</reflink>]; Nelson & Gregg, [<reflink idref="bib52" id="ref51">52</reflink>]). It has also been reported that girls may be more likely to report negative emotions such as depression and anxiety, but still have better reading performance than boys (Carroll & Iles, [<reflink idref="bib6" id="ref52">6</reflink>]).</p> <p>However, some studies have found no significant gender differences in the association between mental health and reading disabilities (Carroll et al., [<reflink idref="bib7" id="ref53">7</reflink>]; Hampton & Mason, [<reflink idref="bib26" id="ref54">26</reflink>]; Sena et al., [<reflink idref="bib63" id="ref55">63</reflink>]). These mixed findings suggest that while gender plays a role in the relationship between mental health and poor reading, the exact nature of this relationship is still not fully understood. Given the potential role of gender differences in mental health and reading issues, it is important to consider or control gender when examining the association between mental health and reading. Doing so can help us better understand the potential gender-specific factors that may contribute to mental health and reading difficulties, and ultimately, design more effective interventions and strategies to support those who are struggling.</p> <hd id="AN0175279629-5">Age</hd> <p>Another particular area of concern in the relationship between RD and mental health is age. As children with RD progress in age, the manifestation of depression and anxiety symptoms tends to intensify (Kessler et al., [<reflink idref="bib35" id="ref56">35</reflink>]). This could be attributed to the higher academic demands and social pressures encountered by children with RD, thereby negatively influencing their overall well-being and quality of life (Boyes et al., [<reflink idref="bib5" id="ref57">5</reflink>]). The implications extend to impacting their academic and social development (Wilmot et al., [<reflink idref="bib77" id="ref58">77</reflink>]). The increasing age underscores feelings of academic inadequacy and social exclusion, potentially exacerbating preexisting mental health challenges.</p> <hd id="AN0175279629-6">Different types of informants in reporting depression and anxiety</hd> <p>Depression and anxiety in children have been assessed by various types of informants, including (<reflink idref="bib1" id="ref59">1</reflink>) self-report, in which the child reports on their own depression and anxiety problems; (<reflink idref="bib2" id="ref60">2</reflink>) parent-report, in which the child's parent reports on their depression and anxiety problems; and (<reflink idref="bib3" id="ref61">3</reflink>) teacher-report, in which the teacher reports on the child's depression and anxiety problems. However, most depression and anxiety screenings use a single informant (Cohen et al., [<reflink idref="bib12" id="ref62">12</reflink>]). Studies using multi-informant approaches have usually found an association between anxiety and poor reading because various informants view the relationship between anxiety and poor reading differently comprising of all possible relations (Carroll et al., [<reflink idref="bib7" id="ref63">7</reflink>]; Sanson et al., [<reflink idref="bib62" id="ref64">62</reflink>]). In contrast, studies using only a single informant sometimes have not always found such an association (Francis et al., [<reflink idref="bib20" id="ref65">20</reflink>]).</p> <p>Discrepancies have been reported in mental health reports between self-report and reports by others, such as parents or teachers (De Los Reyes et al., [<reflink idref="bib15" id="ref66">15</reflink>]; van de Looij-Jansen et al., [<reflink idref="bib71" id="ref67">71</reflink>]). Parent reports are found to better predict mental health status as parents may be more sensitive to their child's cognitive and emotional states (Johnson et al., [<reflink idref="bib33" id="ref68">33</reflink>]; Salcedo et al., [<reflink idref="bib61" id="ref69">61</reflink>]). However, self-reports, but not parent reports, are found to discriminate between youth with depression and those without (Fristad et al., [<reflink idref="bib21" id="ref70">21</reflink>]; Lewis et al., [<reflink idref="bib40" id="ref71">40</reflink>]). The disagreement among different informants can be interpreted in two ways: a person-centered approach and a variable-centered approach (Cohen et al., [<reflink idref="bib12" id="ref72">12</reflink>]; De Los Reyes et al., [<reflink idref="bib14" id="ref73">14</reflink>]; Martel et al., [<reflink idref="bib42" id="ref74">42</reflink>]). In the person-centered approach, negative biases may stem from caregivers' own perspectives, leading to elevated reports of their children's mental health. Parents and/or teachers may also be less attuned to children's emotional functioning (Martel et al., [<reflink idref="bib42" id="ref75">42</reflink>]). In this view, self-reporting should be prioritized. In the variable-centered approach, parents and/or teachers may be good at reporting observable and behavioral symptoms, while self-reports are more sensitive to internal cognitive and emotional states (De Los Reyes et al., [<reflink idref="bib14" id="ref76">14</reflink>]).</p> <p>A study comparing different methods of assessing mental health showed that parent-report is preferred to child-report, but parent and child report is better than parent-report alone in screening children's mental health (Kuhn et al., [<reflink idref="bib38" id="ref77">38</reflink>]). Additionally, studies indicate that teachers are more likely than parents to notice children's depression and anxiety issues related to academic problems (Mesman & Koot, [<reflink idref="bib49" id="ref78">49</reflink>]) and that teachers' ratings can significantly converge with children's self-reports on depression and anxiety (Epkins, [<reflink idref="bib18" id="ref79">18</reflink>]). Therefore, it is important to compare self, parent, and teacher reports of depressive and anxiety symptoms. Utilizing multiple informants can provide a more complete picture of children's depression and anxiety issues.</p> <hd id="AN0175279629-7">Depression and anxiety in Chinese children with reading difficulties</hd> <p>Most studies on depression and anxiety in children with RD are limited to children reading alphabetic orthographies in Western cultures. Chinese RD is defined as difficulties in recognizing characters that affect vocabulary, spelling, and comprehension (Shu et al., [<reflink idref="bib65" id="ref80">65</reflink>]). Research has shown that Chinese children with RD have deficits in orthographic knowledge, rapid automatized naming, phonological awareness, and morphological awareness (McBride et al., [<reflink idref="bib47" id="ref81">47</reflink>]; Peng et al., [<reflink idref="bib57" id="ref82">57</reflink>]). However, RD is not widely accepted in the Chinese context. Some parents and teachers do not understand RD and attribute children's low reading performance to a lack of effort, intelligence, or carelessness but not a lack of ability (Grant & Dweck, [<reflink idref="bib25" id="ref83">25</reflink>]). Chinese people have been deeply influenced by the Confucius heritage culture, which values effort, respect, and practical acquisition of learning (Tweed & Lehman, [<reflink idref="bib69" id="ref84">69</reflink>]). According to Confucius's doctrines, learning is closely linked to effort, hard work, practice, and group responsibility (Hong, [<reflink idref="bib28" id="ref85">28</reflink>]; Watkins & Biggs, [<reflink idref="bib74" id="ref86">74</reflink>]). In this educational philosophy, the belief is that individuals can achieve academic success through persistent effort, and group responsibility is stressed, encouraging a shared commitment to learning among individuals within a community or family. This emphasis on collective responsibility often shapes the cultural perceptions of success and failure within Confucian heritage societies, impacting how individuals respond to academic challenges, including difficulties in reading.</p> <p>Culture plays a significant role in the awareness of mental states (e.g., Hsu et al., [<reflink idref="bib31" id="ref87">31</reflink>]; Hsu & Alden, [<reflink idref="bib30" id="ref88">30</reflink>]; Xie et al., [<reflink idref="bib79" id="ref89">79</reflink>]). Different ethnic groups have varying attitudes toward mental health due to their cultural values. Some ethnic groups are more susceptible to mental health problems than others (Anderson & Mayers, [<reflink idref="bib2" id="ref90">2</reflink>]). Studies show that African Americans, Latinx, and Asian Americans in the USA experience more depression and anxiety than Caucasian Americans (Ginsburg & Silverman, [<reflink idref="bib23" id="ref91">23</reflink>]; Okazaki, [<reflink idref="bib55" id="ref92">55</reflink>], [<reflink idref="bib56" id="ref93">56</reflink>]; Umana-Taylor & Updegraff, [<reflink idref="bib70" id="ref94">70</reflink>]). Additionally, Asians report higher levels of mental health problems than North Americans because the Confucius culture may lead to high rates of depression or anxiety (Kitayama et al., [<reflink idref="bib36" id="ref95">36</reflink>]). It is even possible that different informants may hold different views regarding children's mental health. In the Chinese culture that is influenced by the Confucius philosophy, parents or teachers may report less depression and anxiety in children with RD because they may attribute RD primarily to lack of effort or intelligence, rather than acknowledging mental health as a potential underlying cause. This cultural perspective influences the way depression and anxiety are perceived and reported by key informants in child's educational and familial environment.</p> <p>Only three studies have examined the roles of depression and anxiety in Chinese children and adolescents with RD (Chung et al., [<reflink idref="bib10" id="ref96">10</reflink>]; Wang, [<reflink idref="bib72" id="ref97">72</reflink>]; Xiao et al., [<reflink idref="bib78" id="ref98">78</reflink>]). Wang ([<reflink idref="bib72" id="ref99">72</reflink>]) compared the depression and anxiety of 132 Chinese children in grades 3–6 with and without RD in Taiwan. The study found that children with RD reported higher levels of depression than TD controls, and female children with RD had significantly higher anxiety than their peers. However, only self-reports of depression and anxiety were used in Wang's ([<reflink idref="bib72" id="ref100">72</reflink>]) study. Furthermore, Xiao et al. ([<reflink idref="bib78" id="ref101">78</reflink>]) used a dyslexia checklist and a pupil-rating scale to screen Chinese children in grades 2–6 with RD in Mainland China. They found that Chinese children with RD self-reported more depression but not anxiety than their TD peers. Additionally, RD could affect depression and anxiety symptoms via the mediating effect of stress and time spent on homework. In another study, Chung et al. ([<reflink idref="bib10" id="ref102">10</reflink>]) compared 60 Chinese adolescents with RD to 60 controls on general anxiety and reading anxiety. The results showed that adolescents with RD reported higher levels of general anxiety and reading anxiety than controls, which indicated the importance of considering anxiety while supporting Chinese adolescents with RD.</p> <hd id="AN0175279629-8">The present study</hd> <p>This study aimed to compare the prevalence of depression and anxiety in Chinese children with reading disabilities (RD) to those typically developing (TD) peers across different age groups. In addition, different types of informant reports of depression and anxiety were compared to further understand mental health problems of Chinese children with RD. We focused on Chinese grades 3, 4, and 5 children with and without RD because younger children may be too young to self-rate their depression and anxiety problems. This age range may witness a pronounced increase in the prevalence of mental health issues, possibly associated with persistent RD. Since gender and attention may impact the association between RD and mental health, we controlled for both in the analyses. Although the three existing studies have examined depression and anxiety of Chinese children and adolescents with RD (see Chung et al., [<reflink idref="bib10" id="ref103">10</reflink>]; Wang, [<reflink idref="bib72" id="ref104">72</reflink>]; Xiao et al., [<reflink idref="bib78" id="ref105">78</reflink>]), none of them considered attention problem nor compared different informants regarding children's level of depression and anxiety.</p> <hd id="AN0175279629-9">Method</hd> <p></p> <hd id="AN0175279629-10">Participants</hd> <p>Participants were 1535 children in grades 3 (<emph>N</emph> = 421), 4 (<emph>N</emph> = 477), and 5 (<emph>N</emph> = 483) from three elementary schools in Xi'an, China, with a mean age of 9.87 ± 1.27 (796 were boys, accounting for 51.9% of the sample). The three elementary schools fall under the jurisdiction of the same administration. They use the same textbooks and instructional methods, and children in these schools come from families of similar socioeconomic status. The children whose parents signed the consent forms participated in the study.</p> <p>This study used a standardized Chinese Reading Achievement Test (Dong & Lin, [<reflink idref="bib16" id="ref106">16</reflink>]), which is the only standardized reading achievement test in Mainland China and has been used widely to assess children's reading ability (Tao et al., [<reflink idref="bib68" id="ref107">68</reflink>]; Wang et al., [<reflink idref="bib73" id="ref108">73</reflink>]; Zhou et al., [<reflink idref="bib80" id="ref109">80</reflink>]). The children who scored 1.5 standard deviations below their grade level mean of the test were identified as having RD. Those who had significant cognitive and behavioral problems, psychiatric disturbances, and serious vision or hearing impairment were excluded. Table 1 displays the results, revealing that 154 children were identified as having RD. Among those were 45 of 421 third graders (9.66%), 38 of 477 fourth graders (7.83%), and 71 of 483 fifth graders (12.82%).</p> <p>Table 1 Demographic characteristics of grade × gender × reading difficulties (<emph>N</emph> = 1535)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Grade level</p></th><th align="left"><p>Gender</p></th><th align="left"><p>TD students</p></th><th align="left"><p>RD students</p></th></tr></thead><tbody><tr><td align="left" rowspan="6"><p>Third</p></td><td align="left" rowspan="2"><p>Girl</p></td><td align="left"><p>198</p></td><td align="left"><p>21</p></td></tr><tr><td align="left"><p>42.49%</p></td><td align="left"><p>4.51%</p></td></tr><tr><td align="left" rowspan="2"><p>Boy</p></td><td align="left"><p>223</p></td><td align="left"><p>24</p></td></tr><tr><td align="left"><p>47.85%</p></td><td align="left"><p>5.15%</p></td></tr><tr><td align="left" rowspan="2"><p>Total</p></td><td align="left"><p>421</p></td><td align="left"><p>45</p></td></tr><tr><td align="left"><p>90.34%</p></td><td align="left"><p>9.66%</p></td></tr><tr><td align="left" rowspan="6"><p>Fourth</p></td><td align="left" rowspan="2"><p>Girl</p></td><td align="left"><p>220</p></td><td align="left"><p>16</p></td></tr><tr><td align="left"><p>42.72%</p></td><td align="left"><p>3.11%</p></td></tr><tr><td align="left" rowspan="2"><p>Boy</p></td><td align="left"><p>257</p></td><td align="left"><p>22</p></td></tr><tr><td align="left"><p>49.90%</p></td><td align="left"><p>4.27%</p></td></tr><tr><td align="left" rowspan="2"><p>Total</p></td><td align="left"><p>477</p></td><td align="left"><p>38</p></td></tr><tr><td align="left"><p>92.62%</p></td><td align="left"><p>7.38%</p></td></tr><tr><td align="left" rowspan="6"><p>Fifth</p></td><td align="left" rowspan="2"><p>Girl</p></td><td align="left"><p>248</p></td><td align="left"><p>36</p></td></tr><tr><td align="left"><p>44.77%</p></td><td align="left"><p>6.50%</p></td></tr><tr><td align="left" rowspan="2"><p>Boy</p></td><td align="left"><p>235</p></td><td align="left"><p>35</p></td></tr><tr><td align="left"><p>42.42%</p></td><td align="left"><p>6.32%</p></td></tr><tr><td align="left" rowspan="2"><p>Total</p></td><td align="left"><p>483</p></td><td align="left"><p>71</p></td></tr><tr><td align="left"><p>87.18%</p></td><td align="left"><p>12.82%</p></td></tr><tr><td align="left" rowspan="6"><p>Total</p></td><td align="left" rowspan="2"><p>Girl</p></td><td align="left"><p>666</p></td><td align="left"><p>73</p></td></tr><tr><td align="left"><p>43.39%</p></td><td align="left"><p>4.76%</p></td></tr><tr><td align="left" rowspan="2"><p>Boy</p></td><td align="left"><p>715</p></td><td align="left"><p>81</p></td></tr><tr><td align="left"><p>46.58%</p></td><td align="left"><p>5.28%</p></td></tr><tr><td align="left" rowspan="2"><p>Total</p></td><td align="left"><p>1381</p></td><td align="left"><p>154</p></td></tr><tr><td align="left"><p>89.97%</p></td><td align="left"><p>10.03%</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note. TD</emph> typically developing, <emph>RD</emph> reading difficulties</p> <hd id="AN0175279629-11">Measures</hd> <p>The Strengths and Weaknesses of Attention-Deficit/Hyperactivity-symptoms and Normal-behaviors (SWAN, Swanson et al., [<reflink idref="bib67" id="ref110">67</reflink>]). The SWAN rating scale comprising 30 items was used to assess children's attention problems. The items measure behavioral characteristics representative of attention skills. In the current study, teachers were asked to evaluate the child by comparing him or her to other children in the same class, on skills such as focusing attention, controlling anxiety, and inhibiting impulsive behavior. On the complete scale, each item was scored from − 3 to + 3 (below average to above average), where 0 (zero) is normal and based upon the population average. The Cronbach's <emph>α</emph> for the current sample was 0.82 for grade 3, 0.85 for grade 4, and 0.83 for grade 5.</p> <p>Children's Depression Inventory – 2nd edition (CDI-2nd; Kovacs, [<reflink idref="bib37" id="ref111">37</reflink>]). The CDI was used to assess children's depression. It includes self-report (28 items), parent-report (17 items), and teacher-report (12 items) of depression, covering negative mood/physical symptoms, negative self-esteem, interpersonal problems, and ineffectiveness. The Cronbach's <emph>α</emph> for the current sample was 0.84 for grade 3, 0.82 for grade 4, and 0.87 for grade 5.</p> <p>Multidimensional Anxiety Scale for Children – 2nd edition (MAS-2nd; March, [<reflink idref="bib41" id="ref112">41</reflink>]). The MASC, a 50-item questionnaire, was used to assess children's anxiety. It is one of the most common measures of anxiety. It includes both self-report and parent-report of anxiety, covering separation anxiety, generalized anxiety disorder, social anxiety, humiliation/rejection, performance fears, obsession and compulsions, physical symptoms, and harm avoidance. The self- and parent-report MASC are identical, except that parents provide responses based on their perception of their child's feelings. The Cronbach's <emph>α</emph> for the current sample was 0.80 for grade 3, 0.79 for grade 4, and 0.86 for grade 5.</p> <p>Chinese Reading Achievement Test. This test is a subtest of a standardized academic achievement test designed by the National Panel on Chinese Child and Youth Psychological Development Characteristics (Dong & Lin, [<reflink idref="bib16" id="ref113">16</reflink>]). The standardized academic achievement test includes the Chinese Reading Achievement Test, Math Achievement Test, and Cognitive Abilities. The Chinese Reading Achievement Test includes levels of grade 2, grades 3 and 4, grades 5 and 6, and grades 7–9. We used levels of grades 3 and 4 and grades 5 and 6 for the current sample. They consisted of four parts: (<reflink idref="bib1" id="ref114">1</reflink>) word knowledge; (<reflink idref="bib2" id="ref115">2</reflink>) sentence comprehension; (<reflink idref="bib3" id="ref116">3</reflink>) literature; and (<reflink idref="bib4" id="ref117">4</reflink>) reading comprehension. The Cronbach's <emph>α</emph> for the current sample was 0.79 for grade 3, 0.84 for grade 5, and 0.90 for grade 5.</p> <hd id="AN0175279629-12">Procedure</hd> <p>The Chinese Reading Achievement Test was first administered by research assistants to all children in their schools in the spring semester. The protocols of SWAN, CDI, and MASC were then administered to children, parents, and teachers via an online platform.</p> <hd id="AN0175279629-13">Statistical analysis</hd> <p>Based on self-report, parent-report, and teacher-report scores, this study utilized multivariate analysis of covariance (MANCOVA) to compare levels of depression and anxiety in Chinese children with and without RD across three age groups. Given that both attention and gender are strongly correlated with RD as well as emotional issues, we included attention and gender as covariates in our analysis. Gender is a binary variable and has been recoded as a dummy variable while used as a covariate. Our study utilized different sources for assessing children's depression or anxiety: self-, parent-, and teacher-report. Although these appeared as three distinct scores, they all measured the same underlying construct, i.e., the children's depression or anxiety. This is analogous to a repeated measures design, and as such, we used repeated measures ANCOVA to further explore differences in children's self-perception and adults' (parents' or teachers') perceptions of their depression and anxiety.</p> <hd id="AN0175279629-14">Results</hd> <p>Table 2 presents the descriptive statistics of children's ADHD (SWAN), child self-report, parent-report, and teacher-report of Children's Depression Inventory (CDI), and self-report and parent-report of Multidimensional Anxiety Scale for Children (MASC). The means and standard deviations of grade and gender (control variables) are provided in the supplementary materials. A serial mean imputation method was utilized to address missing data.</p> <p>Table 2 Descriptive statistics of children's attention-deficit/hyperactivity disorder, depression, and anxiety (<emph>N</emph> = 1535)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" rowspan="2"><p>Range</p></th><th align="left" colspan="2"><p><italic>M</italic> ± <italic>SD</italic></p></th></tr><tr><th align="left"><p>TD students(<italic>N</italic> = 1381)</p></th><th align="left"><p>RD students (<italic>N</italic> = 154)</p></th></tr></thead><tbody><tr><td align="left"><p>SWAN</p></td><td align="left"><p> − 90.00–90.00</p></td><td align="left"><p> − 21.14 ± 33.55</p></td><td align="left"><p> − 2.34 ± 34.57</p></td></tr><tr><td align="left"><p>S-CDI</p></td><td align="left"><p>40–90</p></td><td align="left"><p>53.57 ± 10.16</p></td><td align="left"><p>59.68 ± 11.34</p></td></tr><tr><td align="left"><p>P-CDI</p></td><td align="left"><p>35–89</p></td><td align="left"><p>49.60 ± 7.27</p></td><td align="left"><p>52.86 ± 7.74</p></td></tr><tr><td align="left"><p>T-CDI</p></td><td align="left"><p>40–90</p></td><td align="left"><p>46.67 ± 6.33</p></td><td align="left"><p>51.67 ± 9.23</p></td></tr><tr><td align="left"><p>S-MASC</p></td><td align="left"><p>40–79</p></td><td align="left"><p>45.69 ± 6.99</p></td><td align="left"><p>46.25 ± 7.85</p></td></tr><tr><td align="left"><p>P-MASC</p></td><td align="left"><p>40–88</p></td><td align="left"><p>49.26 ± 9.10</p></td><td align="left"><p>50.96 ± 10.60</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. <emph>TD</emph> typically developing, <emph>RD</emph> reading difficulties, <emph>SWAN</emph> The Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale, <emph>CDI</emph> Children's Depression Inventory, <emph>MASC</emph> Multidimensional Anxiety Scale for Children. S- means self-report, P- means parent report, T- means teacher report</p> <p>The results from MANCOVA in Table 3 show that there were significant differences in both self-report CDI (<emph>F</emph><subs>(<reflink idref="bib2" id="ref118">2</reflink>,1527)</subs> = 6.327, <emph>p</emph> = 0.002, <emph>η</emph><sups>2</sups> = 2.008) and teacher-report CDI across grade levels (<emph>F</emph><subs>(<reflink idref="bib2" id="ref119">2</reflink>,1527)</subs> = 10.100, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.013). The post hoc tests with a Bonferroni correction revealed that fifth graders (<emph>M</emph> = 55.12 ± 11.37) scored higher on self-report CDI than third graders (<emph>M</emph> = 53.42 ± 9.83), <emph>t</emph> = 2.522, <emph>df</emph> = 1018, <emph>p</emph> < 0.0167, <emph>d</emph> = 0.16. In contrast, teacher-reported CDI scores were higher for third graders (48.47 ± 7.99) compared to the other groups (46.40 ± 5.72; 46.79 ± 6.61) (<emph>t</emph> = 4.124, <emph>df</emph> = 979, <emph>p</emph> < 0.0167, <emph>d</emph> = 0.30; <emph>t</emph> = 3.677, <emph>df</emph> = 1018, <emph>p</emph> < 0.0167, <emph>d</emph> = 0.23).</p> <p>Table 3 MANCOVA test on depression and anxiety (<emph>N</emph> = 1535)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="2"><p>S-CDI</p></th><th align="left" colspan="2"><p>P-CDI</p></th><th align="left" colspan="2"><p>T-CDI</p></th><th align="left" colspan="2"><p>S-MASC</p></th><th align="left" colspan="2"><p>P-MASC</p></th></tr><tr><th align="left"><p>F</p></th><th align="left"><p>η<sup>2</sup></p></th><th align="left"><p>F</p></th><th align="left"><p>η<sup>2</sup></p></th><th align="left"><p>F</p></th><th align="left"><p>η<sup>2</sup></p></th><th align="left"><p>F</p></th><th align="left"><p>η<sup>2</sup></p></th><th align="left"><p>F</p></th><th align="left"><p>η<sup>2</sup></p></th></tr></thead><tbody><tr><td align="left"><p>Gender</p></td><td align="left"><p>0.001</p></td><td align="left"><p>0</p></td><td align="left"><p>19.438***</p></td><td align="left"><p>0.013</p></td><td align="left"><p>56.225***</p></td><td align="left"><p>0.036</p></td><td align="left"><p>4.554*</p></td><td align="left"><p>0.003</p></td><td align="left"><p>1.303</p></td><td align="left"><p>0.001</p></td></tr><tr><td align="left"><p>SWAN</p></td><td align="left"><p>45.504***</p></td><td align="left"><p>0.029</p></td><td align="left"><p>36.334***</p></td><td align="left"><p>0.023</p></td><td align="left"><p>129.751***</p></td><td align="left"><p>0.078</p></td><td align="left"><p>10.548**</p></td><td align="left"><p>0.007</p></td><td align="left"><p>13.580***</p></td><td align="left"><p>0.009</p></td></tr><tr><td align="left"><p>Grade</p></td><td align="left"><p>6.327**</p></td><td align="left"><p>0.008</p></td><td align="left"><p>0.871</p></td><td align="left"><p>0.001</p></td><td align="left"><p>10.100***</p></td><td align="left"><p>0.013</p></td><td align="left"><p>1.148</p></td><td align="left"><p>0.002</p></td><td align="left"><p>0.600</p></td><td align="left"><p>0.001</p></td></tr><tr><td align="left"><p>RD</p></td><td align="left"><p>24.811***</p></td><td align="left"><p>0.016</p></td><td align="left"><p>15.052***</p></td><td align="left"><p>0.010</p></td><td align="left"><p>54.074***</p></td><td align="left"><p>0.034</p></td><td align="left"><p>0.068</p></td><td align="left"><p>0</p></td><td align="left"><p>3.010</p></td><td align="left"><p>0.002</p></td></tr><tr><td align="left"><p>Grade × RD</p></td><td align="left"><p>2.486</p></td><td align="left"><p>0.003</p></td><td align="left"><p>0.501</p></td><td align="left"><p>0.001</p></td><td align="left"><p>2.000</p></td><td align="left"><p>0.003</p></td><td align="left"><p>0.038</p></td><td align="left"><p>0</p></td><td align="left"><p>0.927</p></td><td align="left"><p>0.001</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. <emph>RD</emph> reading difficulties, <emph>SWAN</emph> The Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale, <emph>CDI</emph> Children's Depression Inventory, <emph>MASC</emph> Multidimensional Anxiety Scale for Children. S- means self-report, P- means parent report, T- means teacher report <sups>*</sups> <.05, ** <.01, *** <.001</p> <p>Compared to TD peers, children with RD scored higher on self-report (59.68 ± 11.34 <emph>vs.</emph> 53.57 ± 10.16), parent-report (52.86 ± 7.74 <emph>vs.</emph> 49.60 ± 7.28), and teacher-report CDI (51.67 ± 9.24 <emph>vs.</emph> 46.67 ± 6.33), respectively (<emph>F</emph><subs>(<reflink idref="bib1" id="ref120">1</reflink>,1527)</subs> = 24.811, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.016; <emph>F</emph><subs>(<reflink idref="bib1" id="ref121">1</reflink>,1527)</subs> = 15.052, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.010; <emph>F</emph><subs>(<reflink idref="bib1" id="ref122">1</reflink>,1527)</subs> = 54.074, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.034). However, for anxiety, as displayed in Table 3, no significant differences were observed in self-report MASC nor parent-report MASC across different grade levels. Also, there was no difference between RD and TD children.</p> <p>Furthermore, Table 4 reveals the results of repeated measures ANCOVA, which examined the within-subject contrast test, i.e., whether differences in scores between children's self-reports and reports from others were associated with RD and grade level while controlling for gender and attention. There was an interaction effect of grade and RD on the difference between self-report and teacher-report CDI scores (<emph>F</emph><subs>(<reflink idref="bib2" id="ref123">2</reflink>,1527)</subs> = 4.090, <emph>p</emph> = 0.017, <emph>η</emph><sups>2</sups> = 0.005). The perception gap between teachers and children widened significantly in the fifth grade for children with RD. Additionally, children with RD exhibited a larger discrepancy between their self-report and parent-report CDI scores compared to their TD peers (<emph>F</emph><subs>(<reflink idref="bib1" id="ref124">1</reflink>,1527)</subs> = 6.118, <emph>p</emph> = 0.013, <emph>η</emph><sups><emph>2</emph></sups> = 0.004). The parent–child perception in CDI showed a significant difference among grades (<emph>F</emph><subs>(<reflink idref="bib2" id="ref125">2</reflink>,1527)</subs> = 6.188, <emph>p</emph> = 0.013, <emph>η</emph><sups><emph>2</emph></sups> = 0.004), with the largest gap observed in fifth graders. For the MASC score, a greater parent–child perception gap was found among children with RD compared to their TD peers (<emph>F</emph><subs>(<reflink idref="bib1" id="ref126">1</reflink>,1527)</subs> = 3.963, <emph>p</emph> = 0.047, <emph>η</emph><sups><emph>2</emph></sups> = 0.003). And the parent–child perception in MASC differed significantly across grades, (<emph>F</emph><subs>(<reflink idref="bib2" id="ref127">2</reflink>,1527)</subs> = 4.192, <emph>p</emph> = 0.015, <emph>η</emph><sups><emph>2</emph></sups> = 0.005). The gap between parent-report and self-report MASC among both third and fourth graders was larger than fifth graders.</p> <p>Table 4 Repeated measures ANCOVA test of between-subject contrasts on depression and anxiety (<emph>N</emph> = 1535)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" rowspan="2" /><th align="left" colspan="2"><p>CDI</p></th><th align="left" colspan="2"><p>MASC</p></th></tr><tr><th align="left"><p><italic>F</italic></p></th><th align="left"><p><italic>η</italic><sup><italic>2</italic></sup></p></th><th align="left"><p><italic>F</italic></p></th><th align="left"><p><italic>η</italic><sup><italic>2</italic></sup></p></th></tr></thead><tbody><tr><td align="left" rowspan="2"><p>Gender</p></td><td align="left"><p>Self-report vs. parent-report</p></td><td char="." align="char"><p>12.683***</p></td><td align="left"><p>0.008</p></td><td char="." align="char"><p>0.405</p></td><td align="left"><p>0</p></td></tr><tr><td align="left"><p>Self-report vs. teacher-report</p></td><td char="." align="char"><p>18.527***</p></td><td align="left"><p>0.012</p></td><td char="." align="char" /><td align="left" /></tr><tr><td align="left" rowspan="2"><p>SWAN</p></td><td align="left"><p>Self-report vs. parent-report</p></td><td char="." align="char"><p>7.558**</p></td><td align="left"><p>0.005</p></td><td char="." align="char"><p>2.425</p></td><td align="left"><p>0.002</p></td></tr><tr><td align="left"><p>Self-report vs. teacher-report</p></td><td char="." align="char"><p>0.094</p></td><td align="left"><p>0</p></td><td char="." align="char" /><td align="left" /></tr><tr><td align="left" rowspan="2"><p>Grade</p></td><td align="left"><p>Self-report vs. parent-report</p></td><td char="." align="char"><p>6.188*</p></td><td align="left"><p>0.004</p></td><td char="." align="char"><p>3.963*</p></td><td align="left"><p>0.003</p></td></tr><tr><td align="left"><p>Self-report vs. teacher-report</p></td><td char="." align="char"><p>0.143</p></td><td align="left"><p>0</p></td><td char="." align="char" /><td align="left" /></tr><tr><td align="left" rowspan="2"><p>RD</p></td><td align="left"><p>Self-report vs. parent-report</p></td><td char="." align="char"><p>4.763**</p></td><td align="left"><p>0.006</p></td><td char="." align="char"><p>4.192**</p></td><td align="left"><p>0.005</p></td></tr><tr><td align="left"><p>Self-report vs. teacher-report</p></td><td char="." align="char"><p>12.444***</p></td><td align="left"><p>0.016</p></td><td char="." align="char" /><td align="left" /></tr><tr><td align="left" rowspan="2"><p>Grade × RD</p></td><td align="left"><p>Self-report vs. parent-report</p></td><td char="." align="char"><p>1.461</p></td><td align="left"><p>0.002</p></td><td char="." align="char"><p>2.036</p></td><td align="left"><p>0.003</p></td></tr><tr><td align="left"><p>Self-report vs. teacher-report</p></td><td char="." align="char"><p>4.09*</p></td><td align="left"><p>0.005</p></td><td char="." align="char" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. <emph>RD</emph> reading difficulties, <emph>SWAN</emph> The Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale, <emph>CDI</emph> Children's Depression Inventory, <emph>MASC</emph> Multidimensional Anxiety Scale for Children. S- means self-report, P- means parent report, T- means teacher report <sups>*</sups> <.05, ** <.01, *** <.001</p> <p>Figure 1 illustrates that children generally reported higher levels of depression than what their parents or teachers perceived. This gap was most noticeable among fifth-grade children with RD. In contrast, Fig. 2 shows that children reported lower levels of anxiety compared to what their parents reported. Moreover, the difference was more noticeable for children with RD than those without, and for children in the third and fourth grade compared to children in the fifth grade.</p> <p>Graph: Fig. 1Depression of TD and RD children across grades. Note. TD, typically developing; RD, reading difficulties; CDI, Children's Depression Inventory</p> <p>Graph: Fig. 2Anxiety of TD and RD children across grades. Note. TD, typically developing; RD, reading difficulties; MASC, Multidimensional Anxiety Scale for Children</p> <p>In summary, this study found that (<reflink idref="bib1" id="ref128">1</reflink>) children with RD were experiencing higher levels of depression than children without RD across all grades; (<reflink idref="bib2" id="ref129">2</reflink>) children reported higher levels of depression than what was reported by their teachers or parents, and the difference was more pronounced for fifth graders with RD; (<reflink idref="bib3" id="ref130">3</reflink>) anxiety levels did not differ significantly by grade level or reading status; (<reflink idref="bib4" id="ref131">4</reflink>) parents generally perceived higher anxiety levels in their children than what the children reported themselves, particularly for those with RD.</p> <hd id="AN0175279629-15">Discussion</hd> <p>Depression and anxiety emerged as two of the most prevalent mental health disorders affecting children (Chai et al., [<reflink idref="bib8" id="ref132">8</reflink>]; Meherali et al., [<reflink idref="bib48" id="ref133">48</reflink>]). The substantial number of Chinese children affected by mental health problems underscores the urgency of the situation and calls for our collective attention and support (Chai et al., [<reflink idref="bib8" id="ref134">8</reflink>]; Duan et al., [<reflink idref="bib17" id="ref135">17</reflink>]). It is imperative that we explore the mental health issues in Chinese children, especially those who have RD and may experience higher levels of depression and anxiety, thus prioritizing the mental well-being of our younger generation.</p> <hd id="AN0175279629-16">Comparison of depression in RD and TD children</hd> <p>In general, Chinese children in our study reported more depression than what their teachers reported, and the difference increased with age. Based on child self-report using the CDI, fifth graders reported more depression than third graders, taking into account gender, attention, and reading performance. However, according to teachers, third graders had higher depression scores than fourth and fifth graders. Essentially, Chinese children in upper elementary school self-reported more depression than those in lower elementary school, but their teachers rated lower elementary school students with higher levels of depression. This finding suggests that children may not be aware of their depression problem until they are older in their upper elementary school years, but their teachers have already observed students' depression issues in the lower elementary school years. It is also possible that children experienced more depression when academic demands increased in the upper years in elementary schools, and the teachers failed to acknowledge this increase children themselves reported. The finding highlights the importance of involving both children and teachers in the assessment and support of children with RD and their mental health.</p> <p>Children with RD experienced more depression than their TD peers across all three grade levels, which is consistent with findings reported in previous studies (Arnold et al., [<reflink idref="bib3" id="ref136">3</reflink>]; Francis et al., [<reflink idref="bib20" id="ref137">20</reflink>]; McArthur et al., [<reflink idref="bib46" id="ref138">46</reflink>]; Mugnaini et al., [<reflink idref="bib51" id="ref139">51</reflink>]), including those completed in China (see Wang, [<reflink idref="bib72" id="ref140">72</reflink>]; Xiao et al., [<reflink idref="bib78" id="ref141">78</reflink>]). This indicates that while Chinese children with RD struggle with reading, they may also develop depression issues because poor reading is found to influence mental health (McArthur et al., [<reflink idref="bib46" id="ref142">46</reflink>]). There is also a possibility that pre-existing mental health problems could affect children's reading abilities, ultimately contributing to poor reading outcomes. However, the establishment of a definitive cause-and-effect relationship is hindered by the absence of longitudinal data. Furthermore, reports from all three informants consistently indicated that children with RD experience more depression, suggesting that depression is recognized by all of them as a mental health issue for Chinese elementary school children with RD.</p> <p>Chinese children reported more depression than their parents and teachers. According to the variable-centered approach, parents and teachers may be better equipped to identify behavioral problems, such as sleeping and eating disorders, than internalizing problems, such as depression (De Los Reyes et al., [<reflink idref="bib14" id="ref143">14</reflink>]; Martel et al., [<reflink idref="bib42" id="ref144">42</reflink>]). It is also possible that parents and teachers are not sensitive to children's depression problems. Children may be more accurate in identifying their own depression problems. Additionally, children with RD and their parents have more divergent perceptions on the frequency of depression than TD children and their parents. Furthermore, fifth graders with RD exhibited a larger disparity between their self-perceived level of depression and the observations made by their teachers compared to children with RD in the other two grades. This indicates that children with RD in upper elementary school report more depression than their teachers, potentially due to increased academic workload.</p> <p>In addition to the heightened academic workload in upper elementary school, which may contribute to an increased risk of depression in children, our argument extends to the role of culture in shaping this phenomenon. Specifically, within the Confucius heritage culture, there exists a strong connection between group responsibility or collectivism and the learning process. This cultural context places significant emphasis on sharing individual successes or setbacks with the group, particularly with family members, and defines the self not only in personal terms but also as an extension of one's family (Hong, [<reflink idref="bib28" id="ref145">28</reflink>]). The strong emphasis on group responsibility and family pride can result in elevated academic performance pressure and a heightened risk of depression (Crystal et al., [<reflink idref="bib13" id="ref146">13</reflink>]). This perspective helps elucidate why Chinese children with RD may self-report higher levels of depression compared to observations from their parents and teachers. As these children grow older, they become increasingly aware of the collective responsibility and family honor, leading to heightened feelings of depression when confronted with academic challenges. Conversely, teachers and parents reported lower levels of depression in children with RD. This difference may be attributed to cultural beliefs that prioritize effort over mental health issues in influencing academic performance (Grant & Dweck, [<reflink idref="bib25" id="ref147">25</reflink>]). In this cultural context, there may be a tendency to associate academic difficulties with insufficient effort rather than recognizing potential underlying mental health concerns. This cultural lens influences the interpretation of children's behavior and emotions, shaping the way depression is perceived and reported by different informants.</p> <hd id="AN0175279629-17">Comparison of anxiety in RD and TD children</hd> <p>Our study found no significant differences between children with RD and typically developing children in anxiety levels across the three grade levels. This indicates that children with RD are not at an elevated risk of developing anxiety in the three grades examined. These findings are in line with those of previous studies (Miller et al., [<reflink idref="bib50" id="ref148">50</reflink>]; Riddick et al., [<reflink idref="bib60" id="ref149">60</reflink>]; Xiao et al., [<reflink idref="bib78" id="ref150">78</reflink>]). It appears that Chinese children with RD are not significantly affected by the general anxiety problems. The relationship between RD and anxiety in children is complex. Not all children with RD experience significant anxiety problems. Some of them may develop effective coping strategies that help them manage the challenges associated with RD (Miller et al., [<reflink idref="bib50" id="ref151">50</reflink>]). A positive and supportive learning environment from both school and family can also mitigate the impact of RD on children's mental health problems and contribute to children's overall emotional well-being (Riddick et al., [<reflink idref="bib60" id="ref152">60</reflink>]). However, our finding should be interpreted with some caution because studies have also demonstrated that children with RD can have higher levels of some types of anxiety (e.g., Kargiotidis & Manolitsis, [<reflink idref="bib34" id="ref153">34</reflink>]; Mugnaini et al., [<reflink idref="bib51" id="ref154">51</reflink>]; Nelson & Harwood, [<reflink idref="bib53" id="ref155">53</reflink>]), and one study has shown that Chinese adolescents with RD reported higher level of general anxiety and reading anxiety (see Chung et al., [<reflink idref="bib10" id="ref156">10</reflink>]). It is possible that adolescents are more mature to recognize their anxiety issues, compared to children. Further, we were not able to examine the subtypes of anxiety in this study due to power issue, and further research is needed to confirm our findings and to explore the relationship between reading difficulties and different types of anxiety in more depth.</p> <p>While anxiety levels did not differ significantly between RD and TD children, parents generally perceived higher levels of anxiety in their children than what the children reported for themselves, particularly for RD students. According to the person-centered approach, parents may be more biased toward their children's anxiety symptoms and overestimate the level of anxiety their children are experiencing. Research conducted by De Los Reyes et al. ([<reflink idref="bib14" id="ref157">14</reflink>]) and Martel et al. ([<reflink idref="bib42" id="ref158">42</reflink>]) shows that parents may be more inclined to report higher levels of anxiety in their children than what the children actually feel because parents have their own experiences, worries, and expectations that influence their interpretation of their children's behavior. Furthermore, cultural expectations and norms about a child's development and well-being can play a role. The Confucius culture may lead to high rates of depression or anxiety (Kitayama et al., [<reflink idref="bib36" id="ref159">36</reflink>]). Chinese parents themselves may have high anxiety levels toward RD, which can influence their perception of their children's emotions. Anxious or stressed parents are more prone to interpreting their children's behaviors through the lens of anxiety. In addition, Chinese children may have difficulty expressing their emotions or may not fully understand what anxiety entails. Therefore, parents may misinterpret their children's emotions by just replying on their own observations and assumptions without communicating with their children.</p> <p>Interestingly, it has been found that students with RD reported less anxiety than their parents in grade 3 or 4 compared to grade 5. This indicates that children with RD have a greater discrepancy in their perception of their own anxiety compared to what their parents report in the lower elementary grades. A possible explanation for this could be that parents may be more anxious than their children regarding their children's anxiety levels and academic achievement, as found by van de Looij-Jansen et al. ([<reflink idref="bib71" id="ref160">71</reflink>]). This also suggests that parents of children in lower elementary school years are already worried about their children's low reading performance and may attribute it to their children's anxiety levels. It is also possible that younger children with RD might be too young to recognize their own anxiety, while their parents have already observed signs of anxiety. However, we lack data to support either perspective. Future research, especially incorporating interviews with both parents and children, has the potential to shed light on this matter. Regardless of what perspective is supported, it is necessary to educate parents on how to be more aware of their children's feelings and anxiety levels in order to accurately assess their children's anxiety and provide the necessary support their children need.</p> <hd id="AN0175279629-18">Limitations and future directions</hd> <p>While this study provides valuable insights, it has several limitations. First, although we are interested in the role of multiple perspectives for both RD and TD children's depression and anxiety, only the CDI, which assesses depression, includes self-report, parent-report, and teacher-report. The MASCI, which measures anxiety, includes self-report and parent-report only. Future research should use multi-informant protocols for both depression and anxiety. Second, there are numerous subtypes of depression, anxiety, and RD. For example, depression includes major depressive disorder, persistent depressive disorder, and disruptive mood dysregulation disorder, while anxiety includes generalized anxiety, separation anxiety, social anxiety, test anxiety, and trait anxiety, among others (American Psychiatric Association, [<reflink idref="bib1" id="ref161">1</reflink>]). Our study mainly focused on the comparison of RD and TD children in general depression and anxiety because the small sample size of children with RD did not allow us to fully examine the relationships between subtypes of depression and anxiety and RD. Future research should examine different subtypes of depression and anxiety to better identify which subtypes of depression and anxiety are most prevalent in children with RD, allowing for more targeted intervention programs. Third, we only collected cross-sectional data for grades 3, 4, and 5 children. Longitudinal data that track children over a longer period of time are needed to observe true developmental changes across age and time as well as explain the mutual relationship between mental health problems and poor reading performance. The longitudinal research design could also help to identify critical periods in which interventions may be most effective in reducing depression and anxiety of children with RD. Furthermore, interview data from both parents and children should be collected to gain a comprehensive understanding of the discrepancy between parents and children in rating children's depression and anxiety.</p> <hd id="AN0175279629-19">Implications</hd> <p>This study has important implications for education and mental health. It suggests that Chinese children with RD may be at an increased risk for mental health problems and that it is important to assess for these conditions in addition to reading ability. Reading interventions for children with RD should encompass interventions addressing issues related to mental health. Children with RD may experience emotional distress, frustration, and a sense of academic inadequacy, which can significantly impact their mental health. Consequently, it is imperative to implement strategies that not only enhance their reading skills but also provide emotional support and coping mechanisms. This combined approach recognizes the interconnectedness of reading difficulties and mental health and aims to create a more supportive and conducive environment for children's development.</p> <p>The divergence in perceptions of mental health problems by children, parents, and teachers highlights the importance of considering multiple perspectives when assessing and addressing mental health concerns in children with RD. It also underscores the necessity of fostering open communication and understanding among children with RD and their parents and teachers. Such efforts can aid in aligning perceptions and ensuring that appropriate support and interventions are provided to address the unique mental health needs of children with RD effectively.</p> <p>It is crucial to address mental health concerns by providing appropriate interventions and support to individuals with RD. This can include access to mental health services, educational support, and targeted interventions that address both the reading difficulties and the associated mental health issues. Additionally, parents and teachers can work together to create a positive and supportive environment for children with RD, where they can feel valued and accepted for who they are. By doing so, we can help children with RD improve their mental health and overall well-being.</p> <hd id="AN0175279629-20">Data availability</hd> <p>The data that support the findings of this study are available from the corresponding author upon reasonable request.</p> <hd id="AN0175279629-21">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0175279629-22"> <title> References </title> <blist> <bibl id="bib1" idref="ref19" type="bt">1</bibl> <bibtext> American Psychiatric Association. (2013). 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Mental Health among Children with and without Reading Difficulties
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Miao+Li%22">Miao Li</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-6756-8122">0000-0002-6756-8122</externalLink>)<br /><searchLink fieldCode="AR" term="%22Wei+Zhao%22">Wei Zhao</searchLink><br /><searchLink fieldCode="AR" term="%22Mengmeng+Liu%22">Mengmeng Liu</searchLink><br /><searchLink fieldCode="AR" term="%22Lele+Zhang%22">Lele Zhang</searchLink><br /><searchLink fieldCode="AR" term="%22Gen+Li%22">Gen Li</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Annals+of+Dyslexia%22"><i>Annals of Dyslexia</i></searchLink>. 2024 74(1):27-46.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 20
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2024
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="EL" term="%22Grade+3%22">Grade 3</searchLink><br /><searchLink fieldCode="EL" term="%22Primary+Education%22">Primary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Grade+4%22">Grade 4</searchLink><br /><searchLink fieldCode="EL" term="%22Intermediate+Grades%22">Intermediate Grades</searchLink><br /><searchLink fieldCode="EL" term="%22Grade+5%22">Grade 5</searchLink><br /><searchLink fieldCode="EL" term="%22Middle+Schools%22">Middle Schools</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Reading+Difficulties%22">Reading Difficulties</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety+Disorders%22">Anxiety Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Grade+3%22">Grade 3</searchLink><br /><searchLink fieldCode="DE" term="%22Grade+4%22">Grade 4</searchLink><br /><searchLink fieldCode="DE" term="%22Grade+5%22">Grade 5</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22China%22">China</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s11881-023-00296-2
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0736-9387<br />1934-7243
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This study explored the relationship between mental health, i.e., depression and anxiety, and reading difficulties (RD) in Chinese elementary school children. Participants were 1535 grades 3, 4, and 5 students from three elementary schools in Xi'an, China. Children with and without RD were compared to their depression and anxiety. Additionally, children's self-ratings, parents' ratings, and teachers' ratings of depression and anxiety were compared to better understand mental health issues of Chinese children with RD. The findings showed that Chinese children with RD experienced more depression but not anxiety compared to their typically developing peers across all three grade levels. Reports from all three informants consistently reflected that children with RD experienced more depression. However, some inconsistencies were found between self-reported levels of depression and anxiety and the observations made by parents and teachers. Children reported experiencing more depression than their parents and teachers observed but less anxiety than their parents reported. This study emphasizes the importance of understanding the links between RD and mental health and the need for appropriate intervention programs to help children with RD cope with the mental health challenges.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1411004
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1411004
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1007/s11881-023-00296-2
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 20
        StartPage: 27
    Subjects:
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Reading Difficulties
        Type: general
      – SubjectFull: Depression (Psychology)
        Type: general
      – SubjectFull: Anxiety Disorders
        Type: general
      – SubjectFull: Elementary School Students
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Grade 3
        Type: general
      – SubjectFull: Grade 4
        Type: general
      – SubjectFull: Grade 5
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Correlation
        Type: general
      – SubjectFull: China
        Type: general
    Titles:
      – TitleFull: Mental Health among Children with and without Reading Difficulties
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