‘Relative Age and Specific Learning Disorder Diagnosis’ – In Conversation with Dr. Bianca Arrhenius

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With the launch of our third journal,  JCPP Advances, we’re bringing you a series of podcasts that focus on the papers and editors featured in the publication. In this podcast we speak to Dr. Bianca Arrhenius, medical doctor from Helsinki, Finland, and PhD student at the University of Turku, who is lead author on the paper ‘Relative Age and Specific Learning Disorder Diagnosis’.

Bianca summarises the paper and methodology, the implications of the findings for professionals working in education and in child mental health, and highlights that knowledge of the topic is crucial for educational policymaking.

Bianca also discusses whether immature children should start school later than their relatively older peers, whether the school age be should be raised, and the implications of your findings for children and their families.

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Dr. Bianca Arrhenius
Dr. Bianca Arrhenius

Dr. Bianca Arrhenius is a general practitioner working in school and child health care in Helsinki, Finland. Her research work at the Department of Child Psychiatry, University of Turku, focuses on the epidemiology and prenatal risk factors for learning disorders. She is currently completing her thesis and after that she hopes to continue with some interesting post doc projects in the research field of child mental health.


Interviewer: Hello, welcome to a different type of in conversation podcast from the Association for Child & Adolescent Mental Health, ACAMH, where we will look at the paper ‘Relative Age and Specific Learning Disorder Diagnosis’, a Finnish population based cohort study recently released in the first issue of JCPP advances. I’m Jo Carlow, a freelance journalist with a specialism in psychology. I have Dr Bianca Arrhenius with me of the Department for Child Psychiatry at the University of Turku in Finland. Bianca is the first author on this paper and is currently completing her PHD on risk factors for learning disorders. If you’re a fan of our in conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Hi Bianca, thanks so much for joining me. Can you begin with a brief introduction about yourself?

Dr. Bianca Arrhenius: Hi Jo, thanks for inviting me. I’m a medical doctor from Helsinki, Finland, and I’m also a PhD student at the University of Turku, as you mentioned. I’ve done clinical work mostly as a school doctor and in child and maternity health clinics in primary care. And for those listeners who are unfamiliar to the Finnish health care system, in Finland we have these routine health check-ups for children, five times before school age, and three times during the school years. And these are performed by a physician and that is mostly what I’ve been doing.

Interviewer: As mentioned in the intro, you’ve co-authored the paper Relative Age and Specific Learning Disorder Diagnoses, a Finnish population based cohort study published in JCPP Advances. Can you start with a summary of the paper?

Dr. Bianca Arrhenius: Basically, we wanted to see how the relative age, and, by this, I mean if a child is young or old compared to the peers in the same school grade, how this relative age of a child affects the likelihood of receiving specific learning disorder diagnosis. And with specific learning disorders, we’re talking about reading, writing, and math, disorders or combinations of these three, but without intellectual disabilities.

Interviewer: And can you say something about the methodology that you used?

Dr. Bianca Arrhenius: Yeah, we used Finnish national registers to get our data. In Finland and in the Nordic countries overall, we have these registers for all sorts of variables, birth dates, family background factors and later diagnosis. And these can then be used for research. We looked at all children born in Finland between 1996 and 2002 and among them all who were diagnosed with specific learning disorder by age ten in specialised health care. And then we compared the incidences for specific learning disorders by birth month. In Finland, the oldest in the grade are born in January, and the youngest in December. I’ve understood that this is different in the UK.

Interviewer: So you could actually start school when you’re four years old, if you’re a summer born child in the UK?

Dr. Bianca Arrhenius: Yes, so that’s different. Because the school starting age is seven in Finland, then the youngest are six, six and a half, and the oldest are seven and a half.

Interviewer: Yes, it’s quite different. I will ask you about the impact of that later. Can you tell us about your findings?

Dr. Bianca Arrhenius: Yeah. We found that the youngest children, the December born, were nearly twice as likely to receive specific learning disorder diagnosis compared to January born, the oldest. And, also, children born mid-year, in summer, had higher incidences than those born in the beginning of the year. So the finding was not limited to the largest age differences. And these findings are pretty much in line with studies that have looked at relative age and psychiatric diagnosis, ADHD, in particular, special education placement in schools or academic achievement. But we even saw a bit stronger effects for this outcome actually.

Interviewer: I’m just wondering Bianca, your study focused on a Finnish cohort. Can we assume that the findings hold true for other countries too? And so, I’m thinking, in particular, for countries such as the UK where summer born children can be as young as four years old when they start school?

Dr. Bianca Arrhenius: There are a couple of older studies, one from the US, and the other one from the UK, where they looked at parent or school reported learning disorders. And the findings were very similar to ours. So I guess we can assume that the findings hold for most Western countries at least.

Interviewer: How does comorbid ADHD and other learning and coordination disorders influence the relative age effect of being diagnosed with a specific learning disorder?

Dr. Bianca Arrhenius: Yeah. We wanted to look at these comorbid conditions because of the previous findings I mentioned. We know that ADHD is very common among children with specific learning disorders. So we wanted to see if the fact that many of them had ADHD could explain our findings. But, quite surprisingly, in the groups of children with learning disorders and comorbid ADHD or comorbid other developmental disorders of speech, and coordination, the incidences were not higher than in the group with just specific learning disorders. And, actually, the effect of young age was slightly bigger in the group with just specific learning disorders.

Interviewer: How do you account for that?

Dr. Bianca Arrhenius: I’m not sure really, because that’s not what we expected. But, I guess, it kind of underlines that there really is a relative age effect for learning disorders, specifically.

Interviewer: Bianca, what are the implications of your findings for professionals working in education and in child mental health?

Dr. Bianca Arrhenius: Maybe the main point would be not to forget a child’s relative age when screening for, or evaluating, learning disorders. I think that relative age effects are already quite established for ADHD. And probably professionals remember that in their work. But relative age is just as important for learning disorders and learning outcomes in general.

Interviewer: Are there any changes to the referral system that you would recommend, having carried out this research?

Dr. Bianca Arrhenius: Well, that’s a good question. I think that major changes in the referral system would need more replicated findings. And, also, studies on proper screening methods for learning disorders. But I do think that, at least in Finland, the referral process for learning disorders would benefit from common guidelines. Because currently municipalities and even different schools in the same municipality can have quite varying procedures. And, at least, according to our study, this produces referral bias.

Interviewer: What are the implications of your findings for children and their families?

Dr. Bianca Arrhenius: I would say that children who are among the youngest in class might need more encouragement and support from their parents, especially in the first school years when relative age differences are usually the largest. And I can imagine when we talked about that some children in the UK are as young as four when they start, that this is really extra important in countries where children start at a very young age. And, also, that having, or not having, a learning disorder is probably not influenced by when you are born, compared to your peers.

Dr. Bianca Arrhenius: But it seems that relative age really affects whether the system catches the learning disorder or not.

Interviewer: Should the school-age be raised, do you think, in countries where it does start at such a very young age?

Dr. Bianca Arrhenius: Yeah, that’s a really good question, as well. As I said, these relative age differences, from previous studies, are really quite similar, regardless of which country the study was performed in. So, in that sense, it might make sense because we also know that the relative age differences become smaller, through rising age.

Interviewer: Let’s turn to policymakers then. Because in the paper you say knowledge of the topic is crucial for educational policymaking. So what message should policymakers take from your findings?

Dr. Bianca Arrhenius: Yeah. I think that we should encourage greater flexibility in tailoring the school starting age based on children’s individual needs. In Finland, it’s very rare to delay school start. Only around 1% of children are held back yearly and it has been declining in the recent decade. And if we then compare to Denmark, for example, holding back is about ten times more common there. We have seen encouraging findings on mental health outcomes for Danish children who were held back.

Interviewer: Oh, that’s really interesting, isn’t it? Because you do pose the question in your paper whether immature children should start school later than their relatively older peers. I mean, can you elaborate on that idea?

Dr. Bianca Arrhenius: Yeah. So, as I mentioned, individually targeted delaying of school start could be a part of the solution to the problem with referral bias, and inconsistent diagnostics of learning disorders. But this is not a simple question, actually. There are also studies pointing out possible negative aspects of holding back pupils. For example, the disadvantage of being youngest might only shift to other pupils instead.

Interviewer: Oh, okay.

Dr. Bianca Arrhenius: And, also, it might not always be productive to increase the age range in the class either. So I think that further studies are certainly needed in this field.

Interviewer: Okay. And are you planning any follow up research?

Dr. Bianca Arrhenius: Well, at the moment, we don’t have any specific plans to do a follow up study, but it would definitely be something worth looking into. For example, it would be interesting to compare the long term outcomes of relatively young, immature, children who were held back compared to those who were not. Right now, I’m involved in a couple of other projects, studies on prenatal risk factors for learning disorders.

Interviewer: And what else do you have in the pipeline?

Dr. Bianca Arrhenius: Yes, so, I’m I’m trying to finish my thesis, writing the summary, currently, and right now also trying to plan what I will do after the PhD is completed. So I have some ideas, but nothing concrete yet.

Interviewer: OK, oh, well, good luck with that.

Dr. Bianca Arrhenius: Thanks.

Interviewer: Bianca, and, finally, what’s your takeaway message for those listening to our conversation?

Dr. Bianca Arrhenius: I think my main message would be that relative age should not determine whether a child is diagnosed with a specific learning disorder, or any other disorder, for that matter. Recognising this is something we can all become better at, I think. And another takeaway message is the importance of individual support for children, because some need more time than others for maturation and school readiness.

Interviewer: Fantatsic. Bianca, thank you so much. For more details on Dr Bianca Arrhenius, please visit the ACAMH website www.acamh.org and Twitter @ACAMH. ACAMH is spelt A C A M H. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review, and do share with friends and colleagues.


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