Objective: The measures implemented to control the spread of Coronavirus disease 2019 (COVID-19) could affect children’s mental and vision health. Youth particularly from minority and socioeconomically disadvantaged backgrounds were more likely to be impacted by these measures. This study aimed to examine the mental health of children with vision impairment and associated factors in North-western China during the COVID-19 pandemic.

Methods: A cross-sectional study was conducted among 2,036 secondary school children living in Ningxia Hui Autonomous Region. Participants completed a survey on sociodemographic and lifestyle information and answered the Chinese version of the 21-item Depression Anxiety Stress Scales (DASS-21) questionnaire. Presenting visual acuity was measured by a trained enumerator. Multivariate logistic regression analysis was used to identify potential risk factors for mental health problems.

Results: Responses from 1,992 (97.8%) children were included in the analysis after excluding those with incomplete mental health outcome data. The prevalence of depression, anxiety and stress symptoms within the dataset were 28.9, 46.4, and 22.3%, respectively. The distribution of children with different stress levels differed significantly between those with and without vision impairment (p = 0.03). Multivariable logistic regression analyses revealed that depression symptoms decreased with higher parental education (OR, 0.76, 95% confidence intervals (CI):0.63–0.96), longer sleep duration (OR, 0.90, 95% CI: 0.81–0.97) and longer study time (OR, 0.82, 95% CI: 0.74–0.91), whereas they increased with higher recreational screen time (OR, 1.19, 95% CI: 1.08–1.32). Anxiety symptoms decreased with higher parental education (OR, 0.80, 95% CI: 0.66–0.96) and increased with higher recreational screen time (OR, 1.15, 95% CI: 1.04–1.27) and being a left-behind child (OR, 1.26, 95% CI: 1.04–1.54). In addition, stress symptoms decreased with longer sleep duration (OR, 0.92, 95%CI: 0.85–0.99) and increased with higher number of siblings (OR, 1.10, 95% CI: 1.01–1.19), higher recreational screen time (OR, 1.15, 95% CI: 1.04–1.28) and older age (OR,1.12, 95% CI: 1.004–1.24).

Conclusion: A considerable proportion of our sample experienced mental health problems during the pandemic. Healthcare planners in China should consider interventions such as reducing recreational screen time, ensuring sufficient sleep, and timely detection of mental health symptoms among socioeconomically disadvantaged groups.

Flourishing is an evolving wellbeing construct and outcome of interest across the social and biological sciences. Despite some conceptual advancements, there remains limited consensus on how to measure flourishing, as well as how to distinguish it from closely related wellbeing constructs, such as thriving and life satisfaction. This paper aims to provide an overview and comparison of the diverse scales that have been developed to measure flourishing among adolescent and adult populations to provide recommendations for future studies seeking to use flourishing as an outcome in social and biological research. We find that most common scales used to measure flourishing are multi-dimensional and assess features over monthly or yearly intervals, and many have been translated and validated across multiple geographical contexts, including higher- and lower-income countries. Complementing self-report measures with other social, economic, regional, and biological indicators of flourishing may provide a holistic and widely applicable measure of wellbeing that could guide strategies to sustain flourishing societies.

Objective
To test the feasibility and effectiveness of a mindfulness-based intervention in rural-to-urban migrant Chinese children using trained community volunteers.

Method
Migrant students ages 9 to 16 from 5 schools in Shanghai (N = 653) were randomly assigned to a mindfulness only group (n = 167), a mindfulness plus life skills group (n = 118), or a waitlist control group (n = 368). The first 2 groups received an 8-week mindfulness intervention delivered 1 hour weekly by trained community volunteers. The mindfulness plus life skills group received 8 additional hours of skills-based mentorship. Measurements on mindfulness, resilience, and anxiety and depression symptoms were collected before and after intervention. Multivariable regression analyses compared the intervention vs control groups.

Results
Before intervention, there were no significant demographic or outcome measure differences between groups except that students in the intervention groups were slightly older. Students had relatively low levels of mindfulness and prosociality difficulties and similar degrees of depression and anxiety symptoms compared with prior studies. After intervention, no statistically significant differences were found in mean scores for mindfulness, resilience, anxiety, or depression in the intervention vs control groups.

Conclusion
A volunteer-led mindfulness intervention did not significantly benefit migrant Chinese children after 8 weeks. More implementation research is needed for low-cost, scalable, and contextually effective mental health prevention programs.

China's higher education system has undergone a rapid expansion over the last two decades. By drawing on hand-collected data, we explore students' experiences in college and in the labor market post-graduation in the wake of this expansion. According to our data, the largest employer of college graduates in the labor market was the state sector, followed by the domestic private sector. To explain the returns to college education in China, we explore three mechanisms: human capital, social networks, and signaling. We find that human capital measures, apart from a student's college English test scores, cannot explain the college wage premium, whereas both social networks (for example, membership of the Communist Party) and signaling matter significantly. This seems to indicate that in China, connections are crucial for student success in the labor market, whereas the higher education system itself is more a system for selecting talented individuals than it is for educating them. Finally, students allocate their time accordingly, for example, by spending more time studying English in college than any other subject.

This study investigated the association between household characteristics, perceived family support (PFS), and the developmental outcomes (resilience, academic performance, and prosociality) among at-risk students. Our large sample included 1564 primary and secondary school students from poor rural China (M = 11.55 years old). Having a caregiver whose resilience score was in the top 50% of the sample was associated with a 0.48-point increase (or 0.31 d effect size), while having a migrant mother was correlated with a 0.26-point decrease (or 0.17 d effect size). PFS was a significant (p < 0.0001) mediator between household characteristics and developmental outcomes. Our study highlights the link between caregiver resilience and PFS, and the healthy functioning of disadvantaged students in a developing context.

Purpose: We examine how adolescent free time allocation—namely, screen time and outdoor time—is associated with mental health and academic performance in rural China.

Methods: This paper used a large random sample of rural junior high school students in Ningxia (n = 20,375; age=13.22), with data collected from self-reported demographic questionnaires (to assess free time allocation), the Strengths and Difficulties Questionnaire (to assess mental health), and a standardized math test (to measure academic performance). We utilized a multivariate OLS regression model to examine associations between free time allocation and adolescent outcomes, controlling for individual and family characteristics.

Results: Our sample’s screen time and outdoor time both averaged around 1 hour. About 10% of the sample adolescents reported behavioral difficulties, while a similar percentage (11%) reported abnormal prosocial behaviors. Adolescents with higher levels of screen time (> 2 hours) were 3 percentage points more likely to have higher levels of behavioral difficulties (p< 0.001), indicating that excessive screen time was associated with worse mental health. Meanwhile, outdoor time was associated with better mental health, and positive correlations were observed at all levels of outdoor time (compared to no outdoor time, decreasing the likelihood of higher levels of behavioral difficulties by between 3 and 4 percentage points and of lower prosocial scores by between 6 and 8 percentage points; all p’s< 0.001). For academic performance, average daily screen times of up to 1 hour and 1– 2 hours were both positively associated with standardized math scores (0.08 SD, p< 0.001; 0.07 SD, p< 0.01, respectively), whereas there were no significant associations between outdoor time and academic performance.

Conclusion: Using a large sample size, this study was the first to examine the association between adolescent free time allocation with mental health and academic performance, providing initial insights into how rural Chinese adolescents can optimize their free time.

Introduction Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

Methods and analysis We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children’s haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.

As digital devices like computers become more widely available in developing countries, there is a growing need to understand how the time that adolescents spend using these devices for recreational purposes such as playing video games is linked with their mental health outcomes. We measured the amount of time that adolescents in rural China spent playing video games and the association of video game time with their mental health. We collected data from primary and junior high schools in a poor, rural province in northwest China (n = 1603 students) and used the Depression, Anxiety, and Stress Scales (DASS-21) to measure mental health symptoms. The results indicated that the average video game time was about 0.69 h per week. There was a significant association between adolescent video game time and poorer mental health. Each additional hour of playing video games also increased the chance of having moderate or above symptoms. Moreover, boys and non-left-behind children had worse mental health if they played more video games. Our study contributes to literature on the links between recreational screen time and mental health, and it sheds light on an issue addressed by recent government legislation to limit the video game time of minors in China.

The self-esteem of students may be significantly associated with their academic performance. However, past research in developing contexts on this issue is limited, particularly among early adolescents. Using a sample of 3101 students from rural primary and junior high schools in China, this study measured their self-esteem by the Rosenberg Self-Esteem Scale (RSES) and explored its association with academic performance. Our findings indicate that students in rural China had both significantly lower self-esteem and a higher prevalence of low self-esteem when compared to past studies of similarly aged students both from urban China and internationally. Furthermore, there was a strong positive correlation between a student’s self-esteem and academic performance. A one-SD increase in RSES score (indicating better self-esteem) was associated with an increase of 0.12 SD in standardized math scores (p < 0.001), and students with low self-esteem (RSES score < 25) scored lower on math tests by 0.14 SD (p < 0.001), which were robust and consistent when employing the propensity score matching method. Our study expands the growing body of empirical evidence on the link between self-esteem and academic performance among rural youth in developing countries and emphasizes the need to improve their self-esteem with the aim of helping them achieve academically.

Although eyeglasses have been considered a cost-effective way to combat myopia, the empirical evidence of its impacts on improving learning outcomes is inconsistent. This paper provides empirical evidence examining the effect of providing eyeglasses on academic performance between provinces with a different economic level in western China. Overall, we find a significant impact in Intention-to-Treat analysis and a large and significant local average treatment effect of providing free eyeglasses to students in the poor province but not in the other. The difference in impact between the two provinces is not a matter of experimental design, implementation, or partial compliance. Instead, we find that the lack of impact in the wealthier provinces is mainly due to less blackboard usage in class and wealthier households. Our study found that providing free eyeglasses to disadvantaged groups boosted their academic performance more than to their counterparts.

Objectives: To examine the association between mental health and executive dysfunction in general adolescents, and to identify whether home residence and school location would moderate that association.

Design: A population-based cross-sectional study.

Setting: A subsample of the Shanghai Children's Health, Education, and Lifestyle Evaluation-Adolescents project. 16 sampled schools in Shangrao city located in downstream Yangtze River in southeast China (December 2018).

Participants: 1895 adolescents (48.8% male) which were divided into three subpopulations: (A) adolescents who have urban hukou (ie, household registration in China) and attend urban schools (UU, n=292); (B) adolescents who have rural hukou and attend urban schools (RU, n=819) and (C) adolescents who have rural hukou and attend rural schools (RR, n=784).

Measures: The Depression Anxiety and Stress Scale-21 was used to assess adolescent mental health symptoms, and the Behaviour Rating Inventory of Executive Function (parent form) was applied to measure adolescent executive dysfunction in nature setting.

Results: Mental health symptoms were common (depression: 25.2%, anxiety: 53.0%, stress: 19.7%) in our sample, and the prevalence rates were lower among UU adolescents than those among the RR and RU, with intersubgroup differences in screen exposure time explaining most of the variance. We found the three types of symptoms were strongly associated with executive dysfunction in general adolescents. We also observed a marginal moderating effect of urban-rural subgroup on the associations: UU adolescents with depression (OR 6.74, 95% CI 3.75 to 12.12) and anxiety (OR 5.56, 95% CI 1.86 to 16.66) had a higher executive dysfunction risk when compared with RR youths with depression (OR 1.93, 95% CI 0.91 to 4.12) and anxiety (OR 1.80, 95% CI 1.39 to 2.33), respectively.

Conclusions: Rural adolescents experienced more mental health symptoms, whereas urban individuals with mental health problems had a higher executive dysfunction risk.

Resilience can play an important role in enabling disadvantaged students to succeed academically. However, few studies in low-resource contexts have evaluated resilience as a process (including a child’s internal capabilities and external resources, like the internal capabilities of a child’s caregiver) and as an outcome (e.g., academic achievement). In the current study, we examined the associations among students’ self-reported internal capabilities, their external resources (e.g., caregivers’ internal capabilities), and their academic resilience (operationalized as performance on a math test). The study was conducted among 1609 primary and secondary school students in rural China using the Connor–Davidson Resilience Scale (CD-RISC) to measure internal capabilities. Student CD-RISC scores were positively associated with external resources including caregiver CD-RISC scores, maternal education level, high levels of perceived social support, recreational reading, and involvement in group-based activities at school. A one-point increase in students’ CD-RISC scores was associated with a 0.01 SD increase in math score (p < 0.001), and the math scores of students whose CD-RISC scores were in the bottom quartile were 0.18 SD lower than those of their peers (p < 0.01). High levels of perceived social support and recreational reading were also associated with academic resilience in the adjusted equation. Directions for future research and policy implications are discussed.

Behavioral strengths and difficulties among children and adolescents may be significantly associated with their academic performance; however, the evidence on this issue for rural youth in developing contexts is limited. This study explored the prevalence and correlates of mental health from three specific dimensions—internalizing problems, externalizing problems, and prosocial behavior—measured by the Strengths and Difficulties Questionnaire (SDQ), and the association of these dimensions with academic performance in math among a sample of 1500 students in rural China. Our findings indicated that students in rural China had worse behavioral difficulties and poorer prosocial skills when compared to most past studies conducted inside and outside of China. In addition, total difficulties and prosocial scores on the SDQ were significantly associated with student math test scores, as students whose externalizing, internalizing, and prosocial scores were in the abnormal range scored lower in math by 0.35 SD, 0.23 SD, and 0.33 SD, respectively. The results add to the growing body of empirical evidence related to the links between social environment, mental health, and academic performance in developing countries, highlighting the importance of students’ mental health for their academic performance, and of understanding risk factors in the social environment among rural youth in developing countries.

Topic
This systematic review and meta-analysis summarizes existing evidence to establish whether vision impairment, ocular morbidity and their treatment are associated with depression and anxiety in children.

Clinical Relevance
Understanding and quantifying these associations support early detection and management of mental health symptoms in children with vision impairment and ocular morbidity. Additionally, this review provides evidence in favour of insurance coverage for timely strabismus surgery.

Methods
We searched nine electronic databases from inception to February 18, 2021, including observational and interventional studies assessing whether vision impairment and/or ocular morbidity and their treatment are associated with depression and/or anxiety in children. We used narrative synthesis and meta-analysis with the residual maximum likelihood method. A protocol was registered and published on The International Prospective Register of Systematic Reviews (PROSPERO, CRD42021233323).

Results
Among 28,992 studies, 28,956 (99.9%) were excluded as duplicates or unrelated content. Among 36 remaining studies, 21 (58.3%) were observational studies concerning vision impairment, eight (22.2%) were observational studies concerning strabismus, and seven (19.4%) were interventional studies. Vision-impaired children experienced significantly higher scores of depression (Standard Mean Difference [SMD] 0.57, 95% Confidence Interval (CI) 0.26-0.89, 11 studies) and anxiety (SMD 0.61, 95% CI 0.40-0.821, 14 studies) than normally-sighted children. In particular, myopic children experienced higher scores of depression (SMD 0.59, 95% CI 0.36-0.81, six studies) than normally-sighted children. Strabismus surgery significantly improved symptoms of depression (SMD: 0.59 95% CI 0.12-1.06, three studies) and anxiety (SMD: 0.69 95% CI 0.24-1.14, four studies) in children.

Discussion
Among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improved these symptoms. Further randomized controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed. Scaling up access to strabismus surgery could improve the mental health of affected children.

Although children living in low- and middle-income countries (LMICs) account for 90% of the global population of children, depression, and anxiety among children in LMICs have been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. We conducted a large-scale epidemiological study of depression and anxiety among 53,421 elementary and junior high school-aged children across China. The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show a higher risk for both depression and anxiety symptoms, while socioeconomic status has varying associations to depression and anxiety symptoms. Our results also show consistent correlations between depression and anxiety symptoms and standard math test scores. These findings underscore the importance of identification, prevention, and treatment of youth depression and anxiety in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of global mental health.

Extant research continues to establish the importance of teacher job satisfaction to student performance, yet teacher job satisfaction remains under-investigated in rural China. In this paper, we examine the prevalence and correlates of teacher job satisfaction. Using data from 634 teachers across 120 schools in rural China, we find an alarmingly high prevalence of teacher job dissatisfaction: roughly 21% of rural teachers were less than satisfied with their jobs. In addition, we find that several individual- and school-level characteristics, including being a male teacher, being a homeroom teacher, not having a management role in school, being a middle-aged teacher, and a school’s boarding status, are correlated with teacher job dissatisfaction. In sum, the results demonstrate a need for further research and policy interventions to improve teacher job satisfaction in rural schools.

This study documents the COVID-19 disease-control measures enacted in rural China and examines the economic and social impacts of these measures. We conducted two rounds of surveys with 726 randomly selected village informants across seven provinces. Strict disease-control measures have been universally enforced and appear to have been successful in limiting disease transmission in rural communities. The infection rate in our sample was 0.001 per cent, a rate that is near the national average outside of Hubei province. None of the villages reported any COVID-19-related deaths. For a full month during the quarantine, the rate of employment of rural workers was essentially zero. Even after the quarantine measures were lifted, nearly 70 per cent of the villagers still were unable to work owing to workplace closures. Although action has been taken to mitigate the potential negative effects, these disease-control measures might have accelerated the inequality between rural and urban households in China.

Background

Despite rising incomes and rapid economic growth, there remains a significant gender gap in health outcomes among rural children in China. This study examines whether the gender gap in child health is related to the behavior of caregivers when seeking healthcare, and whether healthcare subsidies help to bridge the gender gap in rural health outcomes.

Methods

Focusing on vision care specifically, we draw on data from a randomized controlled trial of 13,100 children in Gansu and Shaanxi provinces in China that provided subsidized eyeglasses to myopic children in one set of schools (henceforth, referred to as the treatment schools) and provided prescription information but not subsidized eyeglasses to myopic children in another set of schools (control schools).

Results

The baseline results reveal that while female students generally have worse vision than male students, they are significantly less likely than male students to be taken by their caregivers to a vision exam. The experimental results indicate, however, that caregivers respond positively to both health information and subsidized healthcare, regardless of the gender of their children. When prescription information is paired with a subsidy voucher for healthcare (a free pair of eyeglasses), the uptake rate rises dramatically.

Conclusions

The gender gap in healthcare can be minimized by implementing subsidized healthcare policies.

Purpose

To study the factors determining spectacle-wear compliance and reasons for non-wear among students in rural China.

Methods

This study was based on a spectacle intervention trial among 162 schools in rural China. Students with refractive errors were randomly assigned to either a free or voucher group to receive spectacles at baseline. Spectacle-wear compliance was assessed through an unannounced follow-up 7 months after spectacles were distributed. Students not wearing spectacles were also asked their reasons for non-wear. The collected data underwent descriptive, bivariate, and logistic regression analyses.

Results

A total of 1904 students received spectacles at baseline, 1826 (95.9%) of whom were present at the 7-month follow-up. Among those students, 41.7% wore their spectacles. There was no significant difference in compliance rates between the free and voucher groups. Predictors of wearing spectacles at follow-up included older age (Odds ratio = 1.56, 95% CI: 1.12–2.19), the severity of refractive error (3.68, 2.23–6.07), wearing spectacles before baseline (3.91, 2.53–6.04) and having friends who wore spectacles (1.87, 1.32–2.63). When students could see the blackboard from their seats (0.68, 0.51–0.89) and thought that wearing spectacles was bad looking (0.76, 0.57–1.00), they were reluctant to wear spectacles. The two main reasons for non-wear were the widespread perception that wearing spectacles would weaken eyesight (32.8%) and the inconvenience of wearing spectacles during activities (23.6%).

Conclusions

The main reason that accounts for the low compliance of spectacle wear was misconceptions around spectacle. School-based spectacle programs should consider enhancing the compliance rates to maximize the benefits of spectacle wear.

School bullying is a widely recognized problem in developed countries, but remains under-investigated in developing countries, especially in remote rural areas. In this paper, we examine the prevalence, correlates, and consequences of bullying victimization and its relation to educational performance and creative attitudes. Using data from 10,528 students across 120 primary schools in rural China, we find an alarmingly high prevalence of bullying victimization and that several individual, family, and school characteristics are correlated with bullying victimization. Analyses indicate students who are bullied frequently score lower in Chinese, reading, and math tests and creative attitudes. Taken together, the results demonstrate a need for further research and policy interventions to reduce bullying in schools.

Research continues to highlight the central relationship between caregivers’ mental health and their children’s development. This study examined the relation between primary caregivers’ mental health and school-aged children’s outcomes, including student mental health, resilience, and academic performance, in rural China. Using cross-sectional data from economically poor areas in the Gansu province, 2989 students (mean age = 11.51, 53.33% male, 46.67% female) and their primary caregivers (74.2% female) completed the 21-item, self-report Depression Anxiety Stress Scale. Students also completed the 25-item Connor-Davidson Resilience Scale and a standardized math test. The results indicated a high prevalence of caregiver depression (31%), stress (39%), and anxiety (24%). Characteristics that were significantly correlated with caregiver mental health issues included being a grandparent, having a low socioeconomic status and low education level, and living in a household with at least one migrant worker. Apart from caregiver stress and student resilience, caregiver mental health issues were negatively correlated with all student outcomes, including student mental health, resilience, and academic performance. Although additional empirical research is needed to investigate the associations between caregiver mental health and student outcomes, our results suggest that rural communities could benefit greatly from programs focused on improving the mental health of caregivers and this, in turn, may have a positive impact on student outcomes.

Purpose: To determine the prevalence of visual impairment and glasses ownership among Han Chinese and Hui minority junior high school children in Ningxia Hui Autonomous Region, China. 

Design: Population-based cross-sectional study. 

Methods: Vision screening was conducted on 20,376 children (age 12–15 years) in all 124 rural junior high schools in Ningxia. Personal and family characteristics, glasses ownership, and academic performance were assessed through a survey questionnaire and standardized mathematics test, respectively. 

Results: The prevalence of visual acuity (VA) ≤6/12 in either eye was significantly higher among Han (54.5%) than Hui (45.2%) children (P<0.001), and was significantly positively associated with age, female sex, Han ethnicity, parental outmigration for work, shorter time spent outside during recess, shorter time spent watching television and higher time spent studying. Among children with VA≤6/12 in both eyes, only 56.8% of Han and 41.5% of Hui children had glasses (P<0.001). Glasses ownership was significantly associated with worse vision, greater family wealth, female sex, higher test scores, age, parental outmigration for work, understanding of myopia and glasses, higher time spent studying and Han ethnicity. 

Conclusion: One of the first of its kind, this report on Han and Hui ethnic schoolchildren confirms a high prevalence of visual impairment among both populations, but slightly higher among the Han. Both groups, especially the Hui, have low rates of glasses ownership. Future interventions and policies designed to improve glasses usage should focus on populations with lower incomes and seek to correct erroneous beliefs about the safety of glasses and efficacy of traditional eye exercises.

Background: Attention deficit hyperactivity disorder (ADHD) is a widely recognized mental health problem in developed countries but remains under-investigated in developing settings. This study examines the prevalence, correlates, and consequences of ADHD symptoms among elementary school students in rural China. Methods: Cross-sectional data were collected from 6,719 students across 120 rural primary schools in China on ADHD symptoms, demographic characteristics, and academic performance in reading and math. ADHD symptoms were evaluated using the caregiver-reported ADHD Rating Scale-IV. Results: The prevalence of ADHD symptoms was 7.5% in our sample. Male students, students in lower grade levels, and students with lower cognitive ability showed a significantly higher prevalence of ADHD symptoms (ORs = 2.56, 2.06, and 1.84, respectively; p<0.05). Left-behind children showed a significantly lower prevalence of ADHD symptoms than did children who were living with their parents (OR = 0.74, p < 0.05). Adjusted regressions show that students with ADHD symptoms scored 0.12 standardized deviations lower in reading (p < 0.05) and 0.19 standardized deviations lower in math (p < 0.01). Limitations: The ADHD Rating Scale-IV is a screening scale rather than a diagnostic test. Caregiver self-report measures also may underestimate ADHD symptoms for our sample. Conclusions: ADHD is a common disorder among rural students in China and appears to be contributing to poor academic outcomes. The higher prevalence of ADHD among students with low cognitive ability also suggests that many rural children in China face multifactorial learning challenges. Taken together, the findings indicate a need for educators and policymakers in rural China to develop programs to reduce risk and support students with ADHD symptoms.

Assessing the mental health problems encountered by school children and understanding the contributing factors are crucial to inform strategies aimed at improving mental health in low-resource contexts. However, few studies have investigated the mental health problems among disadvantaged children in poorer countries. This study examines the prevalence of mental health problems in rural China and their association with child and family characteristics. The study uses survey data from 9696 children in 120 rural primary schools and measures child mental health using the Strengths and Difficulties Questionnaire (SDQ). Overall, 17.9% of the sample children were found to be in the abnormal range of the SDQ total difficulties scores. The mean score was 12.93 (SD = 4.94). Abnormal scores were associated with child and family characteristics, including older child age (Odds Ratio, OR = 0.704, 95% CI: 0.611, 0.810; p < 0.001), gender (OR = 1.235, 95% CI: 1.112, 1.371; p < 0.001), and academic performance (OR = 0.421, 95% CI: 0.369, 0.480; p < 0.001). Reading time was found to be protective for mental health. Risk factors include excessive screen time (OR = 1.685, 95% CI: 1.409, 2.016; p < 0.001) and being bullied (OR = 3.695, 95% CI: 3.301, 4.136; p < 0.001). Our study suggests that future mental health illness prevention programs in rural China should consider targeting different aspects of children’s social contexts.