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Systematic Review and Meta-analysis: The Association Between Child and Adolescent Depression and Later Educational Attainment

Open AccessPublished:October 29, 2020DOI:https://doi.org/10.1016/j.jaac.2020.10.008

      Objective

      The association between depression and educational attainment in young people is unclear. This systematic review and meta-analysis examines the longitudinal association between depression and subsequent attainment, and its potential effect modifiers and mediators.

      Method

      We searched Embase, PsycINFO, PubMed, ERIC, and the British Education Index from inception to October 23, 2019, conducted citation searching, and contacted authors for articles. Eligible studies reported on the longitudinal association between depression in children and adolescents 4 to 18 years of age and later educational attainment. Two reviewers independently conducted screening, data extraction, and risk of bias assessment. Correlation coefficients were pooled in meta-analysis, and effect modifiers were explored using meta-regression and stratification. Other evidence on confounders, modifiers, and mediators was narratively synthesized. The PROSPERO record for the study is CRD42019123068.

      Results

      A total of 31 studies were included, of which 22 were pooled in meta-analysis. There was a small but statistically significant association between depression and lower subsequent attainment (pooled Fisher z = −0.19, 95% CI = −0.22 to −0.16, I2 = 62.9%). A total of 15 studies also reported an enduring effect after adjusting for various confounders. No statistically significant effect modifiers were identified. Social and school problems may mediate between depression and low attainment.

      Conclusion

      Depression was associated with lower educational attainment, but further research is needed to establish mechanisms. Nonetheless, there is a clear need for mental health and educational support among children and adolescents with depression.

      Key words

      Globally, depression is a leading cause of illness and disability among adolescents.
      World Health Organization
      Health for the world's adolescents: a second chance in the second decade: summary.
      One study estimates that 3.2% of children and adolescents in the United States have depression, with prevalence increasing from 1.7% during middle-childhood (ages 611 years) to 6.1% during adolescence (ages 1217 years), when key educational milestones often take place.
      • Ghandour R.M.
      • Sherman L.J.
      • Vladutiu C.J.
      • et al.
      Prevalence and treatment of depression, anxiety, and conduct problems in US children.
      Characterized by symptoms such as reduced energy, motivation, and concentration, depression in this age group could impair engagement, attendance, and performance at school.
      • Chow C.M.
      • Tan C.C.
      • Buhrmester D.
      Interdependence of depressive symptoms, school involvement, and academic performance between adolescent friends: a dyadic analysis.
      • Finning K.
      • Ukoumunne O.C.
      • Ford T.
      • et al.
      The association between child and adolescent depression and poor attendance at school: a systematic review and meta-analysis.

      Wickersham A, Dickson H, Jones R, et al. Trajectories of educational attainment among children and adolescents diagnosed with depression, and the role of socio-demographic characteristics: a longitudinal, data linkage study [published online ahead of print October 8, 2020]. Br J Psychiatry. doi: https://doi.org/10.1192/bjp.2020.160.

      A recent meta-analysis conducted by Clayborne et al. investigated the association between adolescent depression and psychosocial outcomes during adulthood, including educational attainment.
      • Clayborne Z.M.
      • Varin M.
      • Colman I.
      Systematic review and meta-analysis: adolescent depression and long-term psychosocial outcomes.
      They concluded that adolescent depression was associated with reduced odds for completing high school and entering postgraduate education. However, these outcomes focused on emerging adulthood, and so were not able to capture the more immediate impact that depression is likely to have on attainment while children are still attending school. Indeed, an earlier systematic review by Riglin et al. found various internalizing disorders to negatively predict school grades.
      • Riglin L.
      • Petrides K.V.
      • Frederickson N.
      • Rice F.
      The relationship between emotional problems and subsequent school attainment: a meta-analysis.
      However, both reviews included studies that relied on self-reported attainment, which has demonstrated questionable validity; in particular, there is thought to be an association between depression symptoms and inaccuracy of self-reported grades.
      • Försterling F.
      • Binser M.J.
      Depression, school performance, and the veridicality of perceived grades and causal attributions.
      • Kuncel N.R.
      • Credé M.
      • Thomas L.L.
      The validity of self-reported grade point averages, class ranks, and test scores: a meta-analysis and review of the literature.
      • Niemi R.G.
      • Smith J.
      The accuracy of students' reports of course taking in the 1994 National Assessment of Educational Progress.
      • Rosen J.A.
      • Porter S.R.
      • Rogers J.
      Understanding student self-reports of academic performance and course-taking behavior.
      In addition, both previous reviews had a broader focus on other exposure variables and outcome variables, such that there was limited scope to explore potential mechanisms for how depression during school might affect attainment. With multiple factors thought to be associated with mental health and educational outcomes,
      • DeSocio J.
      • Hootman J.
      Children’s mental health and school success.
      the pathway between depression and attainment potentially comprises a wide range of pupil-, parent-, teacher-, and school-level factors. It is therefore crucial that further review of this topic also seeks to synthesize evidence on effect modifiers and mediators to highlight potential targets for intervention.
      To our knowledge, this is the first meta-analysis to focus exclusively on the longitudinal association between child and adolescent depression and subsequent educational attainment, as measured using school record data. The aim of this study was to provide a more robust estimate of this association, and to give a comprehensive overview of potential effect modifiers and mediators. This will guide future research and clinical interventions that aim to mitigate the long-term impact of mental health problems within educational settings.
      Department of Health and Social Care and Department for Education
      Transforming children and young people’s mental health provision: a green paper.
      Based on previous studies, we hypothesized that depression would negatively predict subsequent educational attainment. As the first study to systematically review the pathway between these, we did not formulate any specific hypotheses regarding potential effect modifiers and mediators.

      Method

      The protocol for this systematic review and meta-analysis can be viewed on PROSPERO at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019123068, and has been published elsewhere.
      • Wickersham A.
      • Epstein S.
      • Sugg H.
      • Stewart R.
      • Ford T.
      • Downs J.
      The association between depression and later educational attainment in children and adolescents: a systematic review protocol.
      This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see Table S1, available online).
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.

       Search Strategy and Inclusion Criteria

      We included studies that (a) investigated and reported results on the relationship between depression diagnosis or depression symptoms (exposure variable, as measured using a standardized diagnostic measure or a named measurement instrument) and later educational attainment (outcome variable, as measured using academic or administrative records); (b) included participants all within the 4- to 18-year age range at exposure variable measurement (recruiting participants from a school year attended by children or adolescents within this age range was considered sufficient evidence of meeting this criterion); (c) made use of data from countries with compulsory education policies; (d) were longitudinal in design, with prospective data collection; (e) were original research published in a peer-reviewed journal; (f) were published in English; and (g) were available in full text.
      We excluded studies that (a) only investigated internalizing symptoms more generally (for instance, encompassing symptoms of anxiety or stress) or other affective disorders (such as bipolar disorder); (b) recruited participants from postsecondary education settings; (c) only investigated school dropout, general intelligence, aptitude, or ability as the outcome; or (d) aimed to conduct or evaluate an intervention during the study period.
      Because of the relationship under study, we were primarily interested in depression during the school years, so we selected the age range of 4 to 18 years to encompass the compulsory school age range in most countries. We also anticipated that studies would report a wide range of measures for educational attainment, and therefore did not impose any additional eligibility criteria relating to outcome measurement. The inclusion and exclusion criteria are discussed in further detail in the published protocol.
      • Wickersham A.
      • Epstein S.
      • Sugg H.
      • Stewart R.
      • Ford T.
      • Downs J.
      The association between depression and later educational attainment in children and adolescents: a systematic review protocol.
      Embase, PubMed, PsycINFO, the Education Resources Information Center, and the British Education Index were initially searched from inception up to November 13, 2018. The date range was unrestricted, but English language limits were applied because of a lack of resources for translation. Search terms were designed to capture studies that investigated the child and adolescent age group, educational attainment, and depression. Key-word searches were applied to titles and abstracts, and subject heading searches were tailored to each database’s thesaurus (see Supplement 1, available online). Backward and forward citation searching of included studies was conducted in Web of Science and Google Scholar, and reference lists of relevant reviews were also searched. Corresponding authors of included studies and experts in the field were contacted to identify additional citations.
      Citations were managed and duplicates removed in EndNote, whereas screening and data extraction were tracked in Microsoft Excel. AW and HS independently screened titles, abstracts, and full texts obtained from electronic database searching, and a sample of those identified from citation searching following an initial screen by AW. Agreement was 90% following independent title and abstract screening, and 97% following independent full text screening. Disagreements were discussed and agreed upon between the 2 reviewers. The search was updated October 23, 2019; because of high agreement during the first screening, AW independently conducted the search update.

       Data Extraction and Analysis

      Data were extracted from eligible studies using a structured coding form, into which AW and HS independently extracted country of study, participant age and gender, additional participant inclusion or exclusion criteria, exposure variable and outcome variable measurement, follow-up period, sample size, confounders investigated, effect modifiers and mediators investigated, and results used in meta-analysis. Authors were e-mailed for information that could not be found in the articles. Ethnicity was later extracted following feedback during peer review. Nationality, as distinct from ethnicity, was not extracted. AW and HS also independently conducted risk of bias assessment using an adapted version of the Newcastle−Ottawa Scale (NOS), which contains additional items to assess sample size and statistical tests, as has been used previously.
      • Epstein S.
      • Roberts E.
      • Sedgwick R.
      • et al.
      Poor school attendance and exclusion: a systematic review protocol on educational risk factors for self-harm and suicidal behaviours.
      • Wells G.
      • Shea B.
      • O’Connell D.
      • et al.
      The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
      • Wickersham A.
      • Leightley D.
      • Archer M.
      • Fear N.T.
      The association between paternal psychopathology and adolescent depression and anxiety: a systematic review.
      Agreement was 80% following risk of bias assessment. AW independently conducted data extraction and risk of bias assessment resulting from the search update.
      The effect sizes most frequently reported by included studies were correlation coefficients (bivariate associations between depression and attainment at a subsequent timepoint, having measured both on continuous scales). Therefore, correlation coefficients were pooled in random-effects meta-analysis, and results from multivariable analyses were summarized in a narrative synthesis. Correlation coefficients were transformed to the Fisher z and pooled in Stata version 15.0 using the metan command (see Supplement 2, available online).
      • Borenstein M.
      • Wiley I.
      Effect sizes based on correlations. In: Borenstein M, Hedges L., Higgins JPT, Rothstein HR, eds..
      • DerSimonian R.
      • Laird N.
      Meta-analysis in clinical trials.
      • Harris R.J.
      • Deeks J.J.
      • Altman D.G.
      • Bradburn M.J.
      • Harbord R.M.
      • Sterne J.A.
      Metan: fixed-and random-effects meta-analysis.
      Where studies reported multiple effect sizes that met the study eligibility criteria, the mean correlation coefficient and sample size were included in meta-analysis, as has been done previously.
      • Williamson V.
      • Creswell C.
      • Fearon P.
      • Hiller R.M.
      • Walker J.
      • Halligan S.L.
      The role of parenting behaviors in childhood post-traumatic stress disorder: a meta-analytic review.
      Heterogeneity was investigated using the Cochran Q and the I2 statistic,
      • Higgins J.P.T.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      and publication bias was assessed with funnel plots and the Egger test.
      • Egger M.
      • Smith G.D.
      • Schneider M.
      • Minder C.
      Bias in meta-analysis detected by a simple, graphical test.
      We additionally stratified the meta-analysis by studies that met at least half of the quality criteria specified on the NOS to assess risk of bias effects. Mean age at baseline (years) and follow-up period (months) were investigated as effect modifiers using random-effects meta-regression.
      • Harbord R.M.
      • Higgins J.P.T.
      Meta-regression in Stata.
      If unavailable, mean age at baseline was estimated from the reported age range or school year. If 1 study reported multiple correlation coefficients relevant to different baseline ages, the coefficients for different ages were included separately in meta-regression. Where follow-up period was stated as a number of semesters, 1 semester was considered to equal 3 months. We conducted sensitivity analyses to investigate the various assumptions underpinning our meta-regressions, for instance, excluding studies in which the follow-up period was estimated from the number of semesters. Two other post hoc sensitivity analyses were conducted to investigate the effects of pooling different depression scales and studies conducted in different countries.

      Results

       Study Characteristics

      In total, 5,714 studies were screened, of which 31 were eligible for inclusion (Figure 1, Table 1,
      • Birchwood J.
      • Daley D.
      Brief report: The impact of attention deficit hyperactivity disorder (ADHD) symptoms on academic performance in an adolescent community sample.
      • Chen X.
      • Li B.
      Depressed mood in Chinese children: development significance for social and school adjustment.
      • Chen X.
      • Yang F.
      • Wang L.
      Relations between shyness-sensitivity and internalizing problems in Chinese children: moderating effects of academic achievement.
      • Chen L.
      • Chen X.
      Affiliation with depressive peer groups and social and school adjustment in Chinese adolescents.
      • Da Fonseca D.
      • Cury F.
      • Santos A.
      • et al.
      When depression mediates the relationship between entity beliefs and performance.
      • Davies J.
      • Sullivan S.
      • Zammit S.
      Adverse life outcomes associated with adolescent psychotic experiences and depressive symptoms.
      • Denault A.-S.
      • Poulin F.
      • Pedersen S.
      Intensity of participation in organized youth activities during the high school years: longitudinal associations with adjustment.
      • Fu R.
      • Chen X.
      • Liu J.
      • Li D.
      Relations between social comparison orientation and adjustment in Chinese adolescents: moderating effects of initial adjustment status.
      • Hood W.
      • Bradley G.L.
      • Ferguson S.
      Mediated effects of perceived discrimination on adolescent academic achievement: a test of four models.
      • Ialongo N.S.
      • Edelsohn G.
      • Kellam S.G.
      A further look at the prognostic power of young children's reports of depressed mood and feelings.
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      • Kim S.Y.
      • Chen Q.
      • Wang Y.
      • Shen Y.
      • Orozco-Lapray D.
      Longitudinal linkages among parent-child acculturation discrepancy, parenting, parent-child sense of alienation, and adolescent adjustment in Chinese immigrant families.
      • Kim S.Y.
      • Wang Y.J.
      • Shen Y.S.
      • Hou Y.
      Stability and change in adjustment profiles among Chinese American adolescents: the role of parenting.
      • Kingery J.N.
      • Erdley C.A.
      • Marshall K.C.
      Peer acceptance and friendship as predictors of early adolescents' adjustment across the middle school transition.
      • Lepore S.J.
      • Kliewer W.
      Violence exposure, sleep disturbance, and poor academic performance in middle school.
      • Liu J.
      • Bullock A.
      • Coplan R.J.
      • Chen X.
      • Li D.
      • Zhou Y.
      Developmental cascade models linking peer victimization, depression, and academic achievement in Chinese children.
      • Luthar S.S.
      Social competence in the school setting: prospective cross-domain associations among inner-city teens.
      • McLeod J.D.
      • Uemura R.
      • Rohrman S.
      Adolescent mental health, behavior problems, and academic achievement.
      • Morales J.R.
      • Guerra N.G.
      Effects of multiple context and cumulative stress on urban children's adjustment in elementary school.
      • Nishina A.
      • Juvonen J.
      • Witkow M.R.
      Sticks and stones may break my bones, but names will make me feel sick: the psychosocial, somatic, and scholastic consequences of peer harassment.
      • Pate C.M.
      • Maras M.A.
      • Whitney S.D.
      • Bradshaw C.P.
      Exploring psychosocial mechanisms and interactions: links between adolescent emotional distress, school connectedness, and educational achievement.
      • Riglin L.
      • Frederickson N.
      • Shelton K.H.
      • Rice F.
      A longitudinal study of psychological functioning and academic attainment at the transition to secondary school.
      • Rockhill C.M.
      • Vander Stoep A.
      • McCauley E.
      • Katon W.J.
      Social competence and social support as mediators between comorbid depressive and conduct problems and functional outcomes in middle school children.
      • Rothon C.
      • Head J.
      • Clark C.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      The impact of psychological distress on the educational achievement of adolescents at the end of compulsory education.
      • Rothon C.
      • Arephin M.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      Structural and socio-psychological influences on adolescents' educational aspirations and subsequent academic achievement.
      • Schwartz D.
      • Gorman A.H.
      • Nakamoto J.
      • Toblin R.L.
      Victimization in the peer group and children's academic functioning.
      • Shahar G.
      • Henrich C.C.
      • Winokur A.
      • Blatt S.J.
      • Kuperminc G.P.
      • Leadbeater B.J.
      Self-criticism and depressive symptomatology interact to predict middle school academic achievement.
      • Steele R.G.
      • Armistead L.
      • Forehand R.
      Family Health Project Research Group
      Concurrent and longitudinal correlates of depressive symptoms among low-income, urban, African American children.
      • Wang M.-T.
      • Sheikh-Khalil S.
      Does parental involvement matter for student achievement and mental health in high school?.
      • Weidman A.C.
      • Augustine A.A.
      • Murayama K.
      • Elliot A.J.
      Internalizing symptomatology and academic achievement: bi-directional prospective relations in adolescence.
      • Zhang W.
      • Zhang L.
      • Chen L.
      • Ji L.
      • Deater-Deckard K.
      Developmental changes in longitudinal associations between academic achievement and psychopathological symptoms from late childhood to middle adolescence.
      Table S2, available online). Sample sizes ranged from n = 129 to n = 7,276.
      • Pate C.M.
      • Maras M.A.
      • Whitney S.D.
      • Bradshaw C.P.
      Exploring psychosocial mechanisms and interactions: links between adolescent emotional distress, school connectedness, and educational achievement.
      ,
      • Steele R.G.
      • Armistead L.
      • Forehand R.
      Family Health Project Research Group
      Concurrent and longitudinal correlates of depressive symptoms among low-income, urban, African American children.
      For those that reported age ranges, age at depression assessment ranged from 6 to 17 years.
      • Hood W.
      • Bradley G.L.
      • Ferguson S.
      Mediated effects of perceived discrimination on adolescent academic achievement: a test of four models.
      ,
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      ,
      • Morales J.R.
      • Guerra N.G.
      Effects of multiple context and cumulative stress on urban children's adjustment in elementary school.
      ,
      • Steele R.G.
      • Armistead L.
      • Forehand R.
      Family Health Project Research Group
      Concurrent and longitudinal correlates of depressive symptoms among low-income, urban, African American children.
      Gender was reasonably balanced, except in 1 study in which only 22% were male participants.
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      All included studies sampled participants from schools, school districts, or the community. In accordance with the inclusion criteria, no associations were reported in which interventions were conducted during the study period; however, 2 samples had undergone interventions prior to the follow-up periods reported in this review.
      • Ialongo N.S.
      • Edelsohn G.
      • Kellam S.G.
      A further look at the prognostic power of young children's reports of depressed mood and feelings.
      ,
      • Lepore S.J.
      • Kliewer W.
      Violence exposure, sleep disturbance, and poor academic performance in middle school.
      Almost all studies used scales and questionnaires to measure depression symptoms; only 1 study reported results from a diagnostic interview.
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      Variants of the Children’s Depression Inventory (such as shortened or translated versions) were the most commonly used depression measurement instruments. Educational attainment was measured using grades and test scores across various subjects, and only 1 study investigated graduation from higher education as an outcome.
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      The follow-up period ranged from less than one school term to 14 years.
      • Da Fonseca D.
      • Cury F.
      • Santos A.
      • et al.
      When depression mediates the relationship between entity beliefs and performance.
      ,
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      Table 1Key Study Characteristics
      First author, year, referenceCountrynEthnicityAge and grade at depression measurementDepression measurementAttainment outcome(s)Follow-up periodTotal risk of bias score (maximum = 11)
      Birchwood,

      2012
      • Birchwood J.
      • Daley D.
      Brief report: The impact of attention deficit hyperactivity disorder (ADHD) symptoms on academic performance in an adolescent community sample.
      United Kingdom324Not reportedMean = 15.55; range = 15−16; year 11HADS (continuous)GCSE points score; GSCE score weighted for number of GCSE entries (continuous)1 school term5
      Chen,

      2000
      • Chen X.
      • Li B.
      Depressed mood in Chinese children: development significance for social and school adjustment.
      China431Not reportedMean = 11.58 (SD = 1.0); 6th gradeCDI (continuous)Chinese and mathematics scores (continuous)2 y8
      Chen,

      2013
      • Chen X.
      • Yang F.
      • Wang L.
      Relations between shyness-sensitivity and internalizing problems in Chinese children: moderating effects of academic achievement.
      China1155Not reportedMean = 9.33 (SD = 0.67); 3rd gradeCDI (continuous)Chinese, mathematics, and English scores (continuous)1 y7
      Chen,

      2019
      • Chen L.
      • Chen X.
      Affiliation with depressive peer groups and social and school adjustment in Chinese adolescents.
      China1430Not reportedMean = 15.43; 7th and 10th gradeCDI (continuous)Chinese, mathematics, and English scores (continuous)1 y9
      Da Fonseca,

      2009
      • Da Fonseca D.
      • Cury F.
      • Santos A.
      • et al.
      When depression mediates the relationship between entity beliefs and performance.
      France353Not reportedMean = 13.25 (SD = 4.3); range = 11−16CDI (continuous)Mathematics grade (continuous)<1 school term4
      Davies,

      2018
      • Davies J.
      • Sullivan S.
      • Zammit S.
      Adverse life outcomes associated with adolescent psychotic experiences and depressive symptoms.
      United Kingdom4398Not reportedRange = 12SMFQ (continuous and binary)Achieving 5 or more A∗−C grades at GCSE (binary); achieving 3 or more A∗−C grades at A level (binary)4 and 6 y7
      Denault,

      2009
      • Denault A.-S.
      • Poulin F.
      • Pedersen S.
      Intensity of participation in organized youth activities during the high school years: longitudinal associations with adjustment.
      Canada362Majority White; 3% Black; 1% Asian; 3% Latino; 3% ArabicMean = 12.38 (SD = 0.42); 7th−9th gradeCDI (continuous)Mathematics and French scores (continuous)1−3 y7
      Fu,

      2018
      • Fu R.
      • Chen X.
      • Liu J.
      • Li D.
      Relations between social comparison orientation and adjustment in Chinese adolescents: moderating effects of initial adjustment status.
      China336Not reportedMean = 14.08 (SD = 0.58); 7th−8th gradeCDI (continuous)Chinese, mathematics and English scores (continuous)1 y7
      Hood,

      2017
      • Hood W.
      • Bradley G.L.
      • Ferguson S.
      Mediated effects of perceived discrimination on adolescent academic achievement: a test of four models.
      Australia244‘Ethnically diverse school’Mean = 13.6 (SD = 1.24); range = 11−17; years 7−10DASS (continuous)Average grade in “all subjects” (continuous)1 semester5
      Ialongo,

      2001
      • Ialongo N.S.
      • Edelsohn G.
      • Kellam S.G.
      A further look at the prognostic power of young children's reports of depressed mood and feelings.
      United States of America62566% African American; 32% European American; 2% Native American, Asian American, and Hispanic AmericanRange = 9−10
      Information provided or confirmed by the author.
      ; 4th grade
      MFQ-PSF (binary)Overall GPA of C or worse (binary)1−2 y9
      Jonsson,

      2010
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      Sweden588Not reportedMean = 16.44 (SD = 0.63)
      Information provided or confirmed by the author.
      ; range = 16-17; first year of upper secondary school
      BDI, CES-D for children, DICA-R-A (binary)Final GPA in upper secondary school (continuous); attained an upper secondary school diploma by age 20 y (binary); graduated from higher education by age 30 y (binary); graduated given that they entered higher education (binary)2−14 y10
      Kim,

      2013
      • Kim S.Y.
      • Chen Q.
      • Wang Y.
      • Shen Y.
      • Orozco-Lapray D.
      Longitudinal linkages among parent-child acculturation discrepancy, parenting, parent-child sense of alienation, and adolescent adjustment in Chinese immigrant families.
      United States of America379Chinese American (mostly from Hong Kong or southern provinces of China)Mean = 13.04 (SD = 0.73); range = 12−15; 7th−8th gradeCES-D (continuous)GPA (excluding physical education courses) and California Standards Test scores in mathematics and English (continuous)4 y6
      Kim,

      2015
      • Kim S.Y.
      • Wang Y.J.
      • Shen Y.S.
      • Hou Y.
      Stability and change in adjustment profiles among Chinese American adolescents: the role of parenting.
      United States of America350Chinese American (mostly from Hong Kong or southern provinces of China; <10 families from Taiwan)Mean = 13.03 (SD = 0.73); range = 12−15; 7th−8th gradeCES-D (continuous)GPA (excluding physical education courses) (continuous)4 y6
      Kingery,

      2011
      • Kingery J.N.
      • Erdley C.A.
      • Marshall K.C.
      Peer acceptance and friendship as predictors of early adolescents' adjustment across the middle school transition.
      United States of America36599% CaucasianMean = 11.17; 5th gradeCDI (continuous)English, science, social studies, and mathematics grades (continuous)6 mo5
      Lepore,

      2013
      • Lepore S.J.
      • Kliewer W.
      Violence exposure, sleep disturbance, and poor academic performance in middle school.
      United States of America49843% White/Caucasian; 24% Latino/Latina; 24% Black/African American; 9% otherMean = 12.8 (SD = 0.44); 7th gradeCDI (continuous)Cumulative GPA across English, mathematics, social studies, and science (continuous)6 mo6
      Liu,

      2018
      • Liu J.
      • Bullock A.
      • Coplan R.J.
      • Chen X.
      • Li D.
      • Zhou Y.
      Developmental cascade models linking peer victimization, depression, and academic achievement in Chinese children.
      China945Not reportedMean = 10.16 (SD = 0.17); 4th−5th gradeCDI (continuous)Chinese, mathematics and English grades (continuous)1 and 2 y8
      Luthar,

      1995
      • Luthar S.S.
      Social competence in the school setting: prospective cross-domain associations among inner-city teens.
      United States of America13840% African American; 27% Hispanic; 9% Asian; 8% Mixed heritageMean = 15.2 (SD = 1.0); 9th gradeCDI (continuous)Mean grade across 4 academic courses (continuous)6 mo7
      McLeod,

      2012
      • McLeod J.D.
      • Uemura R.
      • Rohrman S.
      Adolescent mental health, behavior problems, and academic achievement.
      United States of America470154% White; 19% African American; 17% Latino/Latina; 7% Asian; 1% Native American; 1% otherMean = 16.07 (SD = 1.13); 9th−12th gradeCES-D (binary)Post−Wave I high school GPA (continuous)1−3 y
      Information provided or confirmed by the author.
      8
      Morales,

      2006
      • Morales J.R.
      • Guerra N.G.
      Effects of multiple context and cumulative stress on urban children's adjustment in elementary school.
      United States of America274542% African American; 45% Latino; 13% non-Hispanic WhiteRange = 6−11; 1st−4th gradeCBCL-TRF (continuous)Reading and mathematics scores from Iowa Test of Basic Skills (continuous)2 y5
      Nishina,

      2005
      • Nishina A.
      • Juvonen J.
      • Witkow M.R.
      Sticks and stones may break my bones, but names will make me feel sick: the psychosocial, somatic, and scholastic consequences of peer harassment.
      United States of America152645% Latino (primarily Mexican and Central American); 26% African American; 11% Asian; 9% European American; 8% mixed6th gradeCDI (continuous)GPA across all classes (continuous)1 semester5
      Pate,

      2017
      • Pate C.M.
      • Maras M.A.
      • Whitney S.D.
      • Bradshaw C.P.
      Exploring psychosocial mechanisms and interactions: links between adolescent emotional distress, school connectedness, and educational achievement.
      United States of America727660% White; 20% Black; 6% Asian/Pacific Islander; 1% Native American; 12% other/multiracialMean = 14.71 (SD = 1.09); range = 13−16; 7th−12th gradeCES-D (continuous)Cumulative GPA across all waves (continuous)7 y9
      Riglin,

      2013
      • Riglin L.
      • Frederickson N.
      • Shelton K.H.
      • Rice F.
      A longitudinal study of psychological functioning and academic attainment at the transition to secondary school.
      United Kingdom202Not reportedMean = 11.25 (SD = 0.44); year 7SMFQ (continuous)English, mathematics, and science scores (continuous)2 school terms7
      Rockhill,

      200949
      United States of America52144% Caucasian/White; 26% African; 26% Asian; 4% Native American; 10% HispanicMean = 12.0 (SD = 0.41)
      Estimated from another article that made use of the same or similar data, as recommended by the author.
      ; 6th grade
      MFQ (categorical)Cumulative GPA (continuous)6 mo6
      Rothon,

      2009
      • Rothon C.
      • Head J.
      • Clark C.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      The impact of psychological distress on the educational achievement of adolescents at the end of compulsory education.
      United Kingdom163626% Bangladeshi; 18% White UK; 9% Asian Indian; 7% Pakistani; 6% Black Caribbean; 11% Black African; 4% Black British; 18% otherRange = 13−14; year 9SMFQ (continuous)Achieving 5 or more A∗−C grades at GCSE (binary)1−3 y9
      Rothon,

      2011
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      • Arephin M.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      Structural and socio-psychological influences on adolescents' educational aspirations and subsequent academic achievement.
      United Kingdom249926% Bangladeshi; 20% White UK; 9% Asian Indian; 7% Pakistani; 6% Black Caribbean; 10% Black African; 22% otherRange = 13−14; year 9SMFQ (binary)Achieving 5 or more A∗−C grades at GCSE (binary)2 y7
      Schwartz,

      2005
      • Schwartz D.
      • Gorman A.H.
      • Nakamoto J.
      • Toblin R.L.
      Victimization in the peer group and children's academic functioning.
      United States of America19936% Hispanic; 26% European American; 7% Asian American; 2% African American; 23% other (such as mixed); 6% unclassifiedMean = 9.02 (SD = 0.57); range = 8.01−10.57; 3rd−4th gradeCDI (continuous)GPA and scores on mathematics and reading subscales of the Stanford Achievement Test−Ninth Edition (continuous)1 y6
      Shahar,

      2006
      • Shahar G.
      • Henrich C.C.
      • Winokur A.
      • Blatt S.J.
      • Kuperminc G.P.
      • Leadbeater B.J.
      Self-criticism and depressive symptomatology interact to predict middle school academic achievement.
      United States of America46049% Non-Hispanic White; 26% Hispanic; 22% African American; 3% otherRange = 11−14
      Estimated from another article that made use of the same or similar data, as recommended by the author.
      ; 6th−7th grade
      BDI (continuous)GPA in English/reading, mathematics, social studies, and science (continuous)1 y7
      Steele,

      2000
      • Steele R.G.
      • Armistead L.
      • Forehand R.
      Family Health Project Research Group
      Concurrent and longitudinal correlates of depressive symptoms among low-income, urban, African American children.
      United States of America129African AmericanMean = 8.78 (SD = 1.69); Range = 6-11CDI (continuous)GPA across each academic subject (continuous)12−14 mo8
      Wang,

      2014
      • Wang M.-T.
      • Sheikh-Khalil S.
      Does parental involvement matter for student achievement and mental health in high school?.
      United States of America93553% European American; 40% African American; 7% biracial/other10th gradeCDI (continuous)English, mathematics, science, and social sciences grades (continuous)1 y minimum9
      Weidman,

      2015
      • Weidman A.C.
      • Augustine A.A.
      • Murayama K.
      • Elliot A.J.
      Internalizing symptomatology and academic achievement: bi-directional prospective relations in adolescence.
      United States of America13092% White; 4% Black; 2% Hispanic; 2% AsianMean = 11.17 (SD = 0.38); 6th−9th gradeCDI (continuous)GPA in English, mathematics, history/social studies, and science (continuous)Up to 4 y8
      Zhang,

      2019
      • Zhang W.
      • Zhang L.
      • Chen L.
      • Ji L.
      • Deater-Deckard K.
      Developmental changes in longitudinal associations between academic achievement and psychopathological symptoms from late childhood to middle adolescence.
      China648Nearly all Chinese HanMean = 11.18 (SD = 0.35); range = 95% of children aged 11.15−11.21
      Information provided or confirmed by the author.
      ; 5th−8th grade
      CDI (continuous)Chinese, mathematics, and English scores (continuous)1 y9
      Note: BDI = Beck Depression Inventory; CBCL-TRF = Child Behavior Checklist−Teacher Report Form; CDI = Children's Depression Inventory; CES-D = Center for Epidemiologic Studies of Depression Scale; DASS = Depression Anxiety Stress Scale; DICA-R-A = Diagnostic Interview for Children and Adolescents in the revised form according to DSM-III-R for adolescents; GCSE = General Certificate of Secondary Education; GPA = Grade Point Average; HADS = Hospital Anxiety and Depression Scale; MFQ = Mood and Feelings Questionnaire; MFQ-PSF = Mood and Feelings Questionnaire−Parent Short Form; SMFQ = Short Mood and Feelings Questionnaire.
      a Information provided or confirmed by the author.
      b Estimated from another article that made use of the same or similar data, as recommended by the author.

       Risk of Bias

      The overall quality of included studies was good; the mean NOS score was 7/11, and only 6 studies met less than half of the assessed quality criteria (Table 1; Table S3, available online). However, the representativeness of samples was mixed, and none of the included studies reported power analyses or otherwise justified their sample sizes, such that some of the smaller studies may have been underpowered. Most of the studies controlled for confounders in their design or analysis, and several also adjusted for educational attainment at baseline. Many studies did not fully report results from statistical tests, for instance, omitting named effect estimates, p values, or measures of precision if appropriate (such as standard errors or confidence intervals).

       Meta-analyses

      A total of 22 studies were included in meta-analysis (see Tables S4 and S5, available online). All of the studies combined in meta-analysis reported correlation coefficients between depression symptoms and attainment, as measured using continuous scales, and none of these studies reported using overlapping samples. The remaining 9 studies did not report bivariate associations between continuous measures of depression and attainment at a subsequent timepoint, and so could not be combined in this meta-analysis. Regrettably, they also did not report analyses that were sufficiently comparable to each other to combine into a separate meta-analysis.
      We found a statistically significant negative association between depression and attainment (pooled Fisher z = −0.19, 95% CI = −0.22 to −0.16, z = 13.32, p < .001) (Figure 2). This is equivalent to a pooled correlation coefficient of r = −0.19 (see Supplement 3, available online), a small effect indicating that depression symptoms accounted for 3.6% of the variance in attainment.
      • Borenstein M.
      • Wiley I.
      Effect sizes based on correlations. In: Borenstein M, Hedges L., Higgins JPT, Rothstein HR, eds..
      ,
      • Cohen J.
      Statistical Power Analysis for the Behavioral Sciences.
      There was moderate and statistically significant heterogeneity between the studies [I2 = 62.9%; Q(21) = 56.66, p <.001], and no evidence of publication bias (see Figure S1, available online; Egger test p = .630). Meta-regression did not show any statistically significant effects of follow-up period (p = .934) or age at baseline (p = .989), and this remained the case following sensitivity analyses for the various assumptions of meta-regression (results available from authors upon request). Stratification by study quality (scores above and below 50% on the risk of bias assessment) resulted in similar pooled effect sizes (see Table S6, available online). Other than changes in heterogeneity as might be expected, post hoc sensitivity analyses also yielded similar small but significant pooled effect sizes.
      Figure thumbnail gr2
      Figure 2Meta-analysis of Correlation Coefficients Between Depression and Educational Attainment

       Narrative Synthesis of Potential Effect Modifiers, Mediators, and Confounders

      In all, 22 of the included studies investigated confounding, effect modification, or mediation (see Table S7, available online). A wide range of confounders were considered, such as sociodemographics, other mental health and school problems, and parent and family characteristics. A total of 15 studies still found a statistically significant, negative association between depression and attainment after adjusting for all confounders. Moreover, although our risk of bias analysis showed that only a minority of studies adjusted for educational attainment at baseline, thus limiting scope for inferring the relationship’s direction, 8 of the 12 included studies that did adjust for attainment at an earlier timepoint found a statistically significant association. One study found a weak but significant positive association between depression at age 12 years and performance on Advanced Level examinations (typically obtained at age 18 years in the United Kingdom), even after adjusting for various confounders. The authors attribute this to the Short Mood and Feelings Questionnaire detection of traits relating to neuroticism.
      • Davies J.
      • Sullivan S.
      • Zammit S.
      Adverse life outcomes associated with adolescent psychotic experiences and depressive symptoms.
      This finding was not replicated for performance on General Certificate of Secondary Education examinations (typically obtained at age 16 years), which may also indicate differential impacts by age or school stage.
      The most commonly investigated effect modifier was gender, although findings were inconclusive, with some studies finding a significant association only in male participants,
      • Ialongo N.S.
      • Edelsohn G.
      • Kellam S.G.
      A further look at the prognostic power of young children's reports of depressed mood and feelings.
      ,
      • Riglin L.
      • Frederickson N.
      • Shelton K.H.
      • Rice F.
      A longitudinal study of psychological functioning and academic attainment at the transition to secondary school.
      others only in female participants,
      • Luthar S.S.
      Social competence in the school setting: prospective cross-domain associations among inner-city teens.
      and still more finding no effect of gender.
      • Chen X.
      • Li B.
      Depressed mood in Chinese children: development significance for social and school adjustment.
      ,
      • Lepore S.J.
      • Kliewer W.
      Violence exposure, sleep disturbance, and poor academic performance in middle school.
      ,
      • Liu J.
      • Bullock A.
      • Coplan R.J.
      • Chen X.
      • Li D.
      • Zhou Y.
      Developmental cascade models linking peer victimization, depression, and academic achievement in Chinese children.
      ,
      • McLeod J.D.
      • Uemura R.
      • Rohrman S.
      Adolescent mental health, behavior problems, and academic achievement.
      ,
      • Rothon C.
      • Head J.
      • Clark C.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      The impact of psychological distress on the educational achievement of adolescents at the end of compulsory education.
      ,
      • Shahar G.
      • Henrich C.C.
      • Winokur A.
      • Blatt S.J.
      • Kuperminc G.P.
      • Leadbeater B.J.
      Self-criticism and depressive symptomatology interact to predict middle school academic achievement.
      ,
      • Steele R.G.
      • Armistead L.
      • Forehand R.
      Family Health Project Research Group
      Concurrent and longitudinal correlates of depressive symptoms among low-income, urban, African American children.
      ,
      • Zhang W.
      • Zhang L.
      • Chen L.
      • Ji L.
      • Deater-Deckard K.
      Developmental changes in longitudinal associations between academic achievement and psychopathological symptoms from late childhood to middle adolescence.
      Some found effects of gender that were dependent on the level of other variables such as baseline attainment,
      • Chen X.
      • Li B.
      Depressed mood in Chinese children: development significance for social and school adjustment.
      how attainment was measured,
      • Jonsson U.
      • Bohman H.
      • Hjern A.
      • von Knorring L.
      • Olsson G.
      • von Knorring A.L.
      Subsequent higher education after adolescent depression: a 15-year follow-up register study.
      and level of self-criticism.
      • Shahar G.
      • Henrich C.C.
      • Winokur A.
      • Blatt S.J.
      • Kuperminc G.P.
      • Leadbeater B.J.
      Self-criticism and depressive symptomatology interact to predict middle school academic achievement.
      There was also some evidence that school connectedness and ethnicity moderated the association between depression and attainment; but, as with gender, the modifying effect of ethnic variation was inconsistent.
      • Pate C.M.
      • Maras M.A.
      • Whitney S.D.
      • Bradshaw C.P.
      Exploring psychosocial mechanisms and interactions: links between adolescent emotional distress, school connectedness, and educational achievement.
      ,
      • Lepore S.J.
      • Kliewer W.
      Violence exposure, sleep disturbance, and poor academic performance in middle school.
      ,
      • Rothon C.
      • Head J.
      • Clark C.
      • Klineberg E.
      • Cattell V.
      • Stansfeld S.
      The impact of psychological distress on the educational achievement of adolescents at the end of compulsory education.
      One study also investigated school year as an effect modifier, but did not find a significant effect.
      • Chen L.
      • Chen X.
      Affiliation with depressive peer groups and social and school adjustment in Chinese adolescents.
      Finally, 3 of the included studies investigated possible mediators on the pathway between depression and attainment. These provided some evidence that the association may be partly mediated by peer victimization,
      • Liu J.
      • Bullock A.
      • Coplan R.J.
      • Chen X.
      • Li D.
      • Zhou Y.
      Developmental cascade models linking peer victimization, depression, and academic achievement in Chinese children.
      school connectedness,
      • Pate C.M.
      • Maras M.A.
      • Whitney S.D.
      • Bradshaw C.P.
      Exploring psychosocial mechanisms and interactions: links between adolescent emotional distress, school connectedness, and educational achievement.
      social competence, and social support.
      • Rockhill C.M.
      • Vander Stoep A.
      • McCauley E.
      • Katon W.J.
      Social competence and social support as mediators between comorbid depressive and conduct problems and functional outcomes in middle school children.
      Taken together, these findings are suggestive that higher levels of depression symptoms may be associated with lower levels of social support (as measured in a variety of ways), which in turn may lead to lower attainment. Social support may therefore be a mechanism underlying the negative association between depression and attainment observed in our meta-analysis.

      Discussion

      This systematic review and meta-analysis provides comprehensive evidence for a small but significant longitudinal association between child and adolescent depression symptoms and lower educational attainment, which persisted despite adjustment for a number of potential confounders. The findings also demonstrate that peer victimisation, school connectedness and social support factors may mediate between depression and low attainment. We were unable to conclude whether gender and ethnicity were modifiers on the depression-attainment pathway. Finally, we found sample age and duration of the longitudinal follow-up were not significant effect modifiers.
      The recent review by Clayborne et al.
      • Clayborne Z.M.
      • Varin M.
      • Colman I.
      Systematic review and meta-analysis: adolescent depression and long-term psychosocial outcomes.
      investigated the association between adolescent depression and educational attainment at emerging adulthood. By extending our review to include studies that measured educational attainment during the school years, we identified 29 studies not eligible for inclusion by Clayborne et al. Most of these measured academic performance while participants were still of school age, thereby emphasizing that the negative association between depression and attainment is not merely a problem that presents itself by the completion of secondary education and engagement in higher education. Timely detection and intervention during school is therefore critical. Our findings also update an earlier review by Riglin et al., again identifying 28 studies on the association that they did not capture.
      • Riglin L.
      • Petrides K.V.
      • Frederickson N.
      • Rice F.
      The relationship between emotional problems and subsequent school attainment: a meta-analysis.
      Moreover, we limited our review to studies that measured performance from school records, thereby overcoming known issues with the validity of self-reported attainment, and providing a more robust measure of the association than the previous reviews.
      • Försterling F.
      • Binser M.J.
      Depression, school performance, and the veridicality of perceived grades and causal attributions.
      ,
      • Kuncel N.R.
      • Credé M.
      • Thomas L.L.
      The validity of self-reported grade point averages, class ranks, and test scores: a meta-analysis and review of the literature.
      Unlike these previous reviews, we conducted a narrative synthesis of various effect modifiers and mediators, and demonstrated that there remains a significant gap in available evidence to build a robust pathway model between depression and attainment. In particular, findings relating to gender and ethnicity were varied and inconclusive, and although social support emerged as a potential mediator, it has been inconsistently examined. Given that our results suggest that child- and adolescent-onset depression is a weak but highly modifiable risk factor for low attainment, a fuller understanding of the relationship between depression and attainment is critical. Fuller analyses of the causal pathway should combine the range of potential modifiers and mediators, such as key predictors of attainment and other school factors associated with depression. For instance, a range of other sociodemographic characteristics have been associated with attainment and mental health, such as socioeconomic status and relative age in the school year.
      • Harwell M.
      • Maeda Y.
      • Bishop K.
      • Xie A.
      The surprisingly modest relationship between SES and educational achievement.
      ,
      • Jeronimus B.F.
      • Stavrakakis N.
      • Veenstra R.
      • Oldehinkel A.J.
      Relative age effects in Dutch adolescents: concurrent and prospective analyses.
      Other candidate variables in the pathway might include parent and teacher support,
      • Hill N.E.
      • Tyson D.F.
      Parental involvement in middle school: a meta-analytic assessment of the strategies that promote achievement.
      ,
      • Roorda D.L.
      • Koomen H.M.Y.
      • Spilt J.L.
      • Oort F.J.
      The influence of affective teacher–student relationships on students’ school engagement and achievement: a meta-analytic approach.
      school absence,
      • Finning K.
      • Ukoumunne O.C.
      • Ford T.
      • et al.
      The association between child and adolescent depression and poor attendance at school: a systematic review and meta-analysis.
      pupil engagement,
      • Lei H.
      • Cui Y.
      • Zhou W.
      Relationships between student engagement and academic achievement: a meta-analysis.
      school involvement,
      • Chow C.M.
      • Tan C.C.
      • Buhrmester D.
      Interdependence of depressive symptoms, school involvement, and academic performance between adolescent friends: a dyadic analysis.
      and academic self-efficacy.
      • Honicke T.
      • Broadbent J.
      The influence of academic self-efficacy on academic performance: a systematic review.
      A better understanding of how certain aspects of depression may affect attainment would also be beneficial: for example, whether specific symptoms or the duration of experiencing symptoms has a particularly negative impact on attainment.
      The role of externalizing symptoms in the association is also unclear. A previous narrative review suggested that there was no direct association between internalizing problems (ie, depression and anxiety) and academic outcomes after adjusting for baseline attainment, and that externalizing problems play a more critical role.
      • Suldo S.M.
      • Gormley M.J.
      • DuPaul G.J.
      • Anderson-Butcher D.
      The impact of school mental health on student and school-level academic outcomes: current status of the research and future directions.
      To the contrary, we identified multiple studies in which the association between depression and attainment was robust to baseline adjustments, but the role of externalizing problems does remain uncertain. McLeod et al. concluded that behavior problems were a stronger predictor of attainment than depression, but acknowledged that some externalizing problems such as substance use might be coping responses for children with depression, and may thus be a mediating factor.
      • McLeod J.D.
      • Uemura R.
      • Rohrman S.
      Adolescent mental health, behavior problems, and academic achievement.
      However, Rockhill et al. concluded that depression that is comorbid with conduct problems is a stronger predictor of attainment than either problem in isolation, such that the presence of externalizing comorbidities might be considered an effect modifier in the association between depression and attainment.
      • Rockhill C.M.
      • Vander Stoep A.
      • McCauley E.
      • Katon W.J.
      Social competence and social support as mediators between comorbid depressive and conduct problems and functional outcomes in middle school children.
      This area would benefit from further research.
      This review has a number of strengths. We conducted a thorough search of both health and education databases, and included studies that used named and established depression measures and administrative attainment data to produce as robust an estimate of the association as possible. In part due to our robust inclusion criteria, the risk of bias of included studies was generally low. We also focused on depression symptoms to the exclusion of broader constructs such as “internalizing symptoms” or “psychological distress.” These measures often include symptoms of anxiety, which Weidman et al. argue is motivationally and cognitively distinct from depression, such that its inclusion might obscure the effects of depression symptoms.
      • Weidman A.C.
      • Augustine A.A.
      • Murayama K.
      • Elliot A.J.
      Internalizing symptomatology and academic achievement: bi-directional prospective relations in adolescence.
      This review also has some limitations. Our focus on longitudinal studies with prospective data collection aids inference of a causal direction, but scope for detecting an independent association was limited by our inability to pool effect sizes that adjusted for covariates including prior attainment in meta-analysis. Many included studies did not conduct comparable multivariable analyses, adjusting for a wide range of covariates and variable reporting of results, or did not report their results fully enough to incorporate them into the meta-analysis. Bivariate associations were therefore pooled to maximize the number of studies captured in the meta-analysis.
      Our age range for depression measurement (4−18 years) was designed to encompass the compulsory school age range in most countries, but therefore captures a wide age range and a number of heterogenous developmental periods. We also did not limit inclusion of studies based on length of follow-up in order to investigate its potential effects through meta-regression. Therefore, some of the included studies have a very short follow-up period between depression assessment and outcome ascertainment, further limiting causal inference. However, the majority of included studies included a follow-up period of at least 1 year. In addition, the meta-regression suggested that the strength of the association between depression and attainment was robust to follow-up duration.
      There was no evidence of publication bias, but we were able to include only studies published in the English language. Research in non−English-language journals or regional databases, and particularly research conducted in low- and middle-income countries, might therefore be missed, limiting generalizability to countries not captured by this study.
      • Shenderovich Y.
      • Eisner M.
      • Mikton C.
      • Gardner F.
      • Liu J.
      • Murray J.
      Methods for conducting systematic reviews of risk factors in low-and middle-income countries.
      We also pooled estimates from a wide variety of countries and cultures, despite substantial variation in educational systems. However, we note that our stratified meta-analysis found similar effects after pooling results within the United Kingdom, United States, and China only.
      The included studies were significantly heterogenous, suggesting a role for unexplored effect modifiers. For instance, we were unable to meta-analyze modifying effects of gender because of the limited reporting of correlation coefficients stratified by gender. Finally, the majority of included studies investigated depression symptoms as the exposure variable, rather than depression diagnosis, such that the clinical significance of the reported associations remains unclear.
      Lower school performance can have a lasting impact throughout the life course, predicting unemployment, homelessness, poor health, and suicide attempts.
      • Almquist Y.B.
      School performance as a precursor of adult health: exploring associations to disease-specific hospital care and their possible explanations.
      • Brakenhoff B.
      • Jang B.
      • Slesnick N.
      • Snyder A.
      Longitudinal predictors of homelessness: findings from the National Longitudinal Survey of Youth-97.
      • Caspi A.
      • Wright B.R.E.
      • Moffitt T.E.
      • Silva P.A.
      Early failure in the labor market: childhood and adolescent predictors of unemployment in the transition to adulthood.
      • Sörberg Wallin A.
      • Zeebari Z.
      • Lager A.
      • Gunnell D.
      • Allebeck P.
      • Falkstedt D.
      Suicide attempt predicted by academic performance and childhood IQ: a cohort study of 26 000 children.
      Indeed, our finding that depression can have an impact on grades during the school career appear to extend into educational outcomes in adulthood, as demonstrated by Clayborne et al.
      • Clayborne Z.M.
      • Varin M.
      • Colman I.
      Systematic review and meta-analysis: adolescent depression and long-term psychosocial outcomes.
      In turn, education is associated with long-term economic growth, and therefore has implications at the societal level.
      • Hanushek E.A.
      • Woessmann L.
      Education, knowledge capital, and economic growth.
      Our findings should therefore serve to motivate the development of evidence-based interventions for children and adolescents with depression, and future work should investigate whether detection and treatment of depression symptoms in pupil populations leads to improved educational outcomes.
      • Caldwell D.M.
      • Davies S.R.
      • Hetrick S.E.
      • et al.
      School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis.
      ,
      • Das J.K.
      • Salam R.A.
      • Lassi Z.S.
      • et al.
      Interventions for adolescent mental health: an overview of systematic reviews.
      Observational or trial-based research that develops a pathway model between depression and attainment could inform these efforts and help to reduce the attainment gap relating to child and adolescent depression. It should also be noted that we have focused on the pathway from depression to attainment, and comparatively few of our included studies measured depression and attainment at multiple timepoints, which would be an important inclusion in future studies on this topic. Indeed, some evidence suggests that the relationship may be bi-directional.
      • Weidman A.C.
      • Augustine A.A.
      • Murayama K.
      • Elliot A.J.
      Internalizing symptomatology and academic achievement: bi-directional prospective relations in adolescence.
      A recent genome-wide association meta-analysis found a possible relationship between genetic variation in educational attainment and major depressive disorder.
      • Wray N.R.
      • Ripke S.
      • Mattheisen M.
      • et al.
      Genome-wide association analyses identify 44 risk variants and refine the genetic architecture of major depression.
      As a result, children and adolescents might enter a vicious cycle of poor mental health and school performance, such that interventions targeting depression and learning behaviors may both be beneficial. With this in mind, families, clinicians, and educators should engage in comprehensive approaches that can address modifiable, shared precursors for both depression and poor attainment (such as school absence),
      • Finning K.
      • Ukoumunne O.C.
      • Ford T.
      • et al.
      The association between child and adolescent depression and poor attendance at school: a systematic review and meta-analysis.
      rather than targeting single risk factors in isolation.
      In conclusion, we conducted a comprehensive systematic review and meta-analysis of the association between depression and subsequent educational attainment in children and adolescents, and found evidence for a small but significant negative association. Going forward, the research landscape would benefit from further research on the pathway between depression and educational attainment. Nonetheless, the need for mental health and educational support among children and adolescents who struggle with depression is clear.

      Supplemental Material

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