title: The downward spiral of mental disorders and educational attainment: a systematic review on early school leaving.
abstract: BACKGROUND
  Most psychiatric disorders present symptom patterns that cause severe impairment on the emotional, cognitive and social level. Thus, adolescents who suffer from a mental disorder risk finding themselves in a downward spiral caused by the reciprocal association of psychological symptoms and negative school experiences that may culminate in early school leaving. In addition to previous collective work that mainly focused on school refusing behaviour among children and was presented as an expert's opinion, the following systematic review fills the knowledge gap by providing a structured overview of the bidirectional association between mental health and secondary school dropout based on a sound methodology and with a particular focus on mediating factors.
  
  
  METHODS
  Four electronic databases were searched from January 1990 until June 2014. Selected references were assessed for study details, main results, mediating factors and methodological limitations. Standardized risk of bias assessment was conducted.
  
  
  RESULTS
  Mood and anxiety disorders seemed to have a less consequential direct effect on early school leaving than substance use and disruptive behaviour disorders. The association between externalizing disorders and educational attainment was even stronger when the disorder occurred early in life. On the other hand, internalizing disorders were reported to develop as a consequence of school dropout. Only few studies had addressed gender differences, with discrepant results. Socio-economic background, academic achievement and family support were identified as significant mediating factors of the association between mental disorders and subsequent educational attainment.
  
  
  CONCLUSIONS
  Findings suggested a strong association between mental health and education, in both directions. However, most studies focused on mediating factors that could not be targeted by intervention programs.
authors.affiliation: Centre for Health Studies, Centre de Recherche Public de la Santé, Rue Thomas Edison 1 A-B, Strassen 1445, Luxembourg. pascale.esch@crp-sante.lu.
authors.forename: Pascale
authors.initials: P
authors.lastname: Esch
authors.forename: Valéry
authors.initials: V
authors.lastname: Bocquet
authors.forename: Charles
authors.initials: C
authors.lastname: Pull
authors.forename: Sophie
authors.initials: S
authors.lastname: Couffignal
authors.forename: Torsten
authors.initials: T
authors.lastname: Lehnert
authors.forename: Marc
authors.initials: M
authors.lastname: Graas
authors.forename: Laurence
authors.initials: L
authors.lastname: Fond-Harmant
authors.forename: Marc
authors.initials: M
authors.lastname: Ansseau
mesh_terms: D000293:Adolescent; D001008:Anxiety Disorders / Q000453:epidemiology / Q000523:psychology; D002648:Child; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology* / Q000523:psychology; D008603:Mental Health; D012574:Schools; D013332:Student Dropouts / Q000523:psychology / Q000706:statistics & numerical data*; D019966:Substance-Related Disorders / Q000453:epidemiology / Q000523:psychology