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International Journal of
Environmental Research
and Public Health
Article
The Heterogeneous Effects of Participation in Shadow
Education on Mental Health of High School Students in Taiwan
I-Chien Chen 1, * and Ping-Yin Kuan 2
Citation: Chen, I.-C.; Kuan, P.-Y.
The Heterogeneous Effects of
Participation in Shadow Education on
Mental Health of High School
Students in Taiwan. Int. J. Environ.
Res. Public Health 2021,18, 1222.
https://doi.org/10.3390/ijerph18031222
Academic Editor: Paul B. Tchounwou
Received: 6 January 2021
Accepted: 25 January 2021
Published: 29 January 2021
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Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
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Attribution (CC BY) license (https://
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4.0/).
1College of Education & CREATE for STEM Institute, Michigan State University, East Lansing, MI 48824, USA
2Department of Sociology & International Doctoral Program in Asia-Pacific Studies, National Chengchi
University, Taipei 106011, Taiwan; soci1005@nccu.edu.tw
*Correspondence: ichiench@msu.edu; Tel.: +1-517-432-0439
Abstract:
The effect of shadow education or private supplementary education (PSE) on school
achievement has been prolifically studied, but its impact on well-being remains understudied.
This study examines the heterogeneous effect of PSE participation on school achievement and
depression symptoms among high schoolers in Taiwan. The study uses panel data of the Taiwan
Upper Secondary Database (TUSD) in the 2014 and 2015 academic years. We join the inverse-
probability-of-treatment weighting (IPTW) approach and the seemingly unrelated regression (SUR)
model to estimate the effects of PSE participation patterns on two correlated outcomes, comprehensive
assessment of high school entrance examination and self-reported depression symptoms in the 11th
grade. The latent class analysis identifies five PSE participation patterns: always-taker, early-adopter,
dropout, late-adopter, and explorer, to predict the effect of PSE on the scores of entrance examination
and later depression symptoms in high school (n= 7708, mean age = 15.33). The findings suggest
that PSE participation in junior high is positively associated with academic achievement. However,
PSE participation also increases depression symptoms, particularly in the case of always-takers.
In other words, while always-takers increase their school achievement in transition into high school,
their risks of suffering from depression are also higher than their peers.
Keywords:
private supplementary education; shadow education; depression; entrance examination;
secondary education
1. Introduction
Private supplementary education (PSE) is a form of shadow education and is com-
monly called “buxi” or cram schooling in Taiwan. PSE offers private, fee-paying supplemen-
tary education for academic subjects beyond school walls [
1
–
3
]. Hence, one of the primary
purposes of PSE participation is to obtain high scores at the nationally administered school or
college entrance examination, especially in countries where the competition for enrolling into
a more prestigious high school or university is fierce [
1
,
4
–
7
]. Education researchers noted the
prevalence of PSE participation in East Asian countries in the 1990s [
8
,
9
]. However, PSE
participation has become a worldwide phenomenon in the 21st century [3,10].
The prevalence of PSE is certainly not good news, since the burnout or workload
outside of school may cause the development of depression symptoms [
11
], sleep depriva-
tion [
12
], and stress in school [
13
–
18
]. According to a statistical report by the Ministry of
Education [
19
] in Taiwan, nearly 50 to 70% of junior high students (age 13–15) participated
in PSE, which is high even among East Asian societies [
3
]. Parents’ expectations and
competitive pressure to outperform peers in school results in students carrying weight on
their shoulders from middle to high school.
Previous PSE research, in general, has shown the positive effect of PSE on students’
academic achievement [
6
,
7
,
13
,
20
,
21
] and entrance examination [
2
–
4
,
8
,
22
,
23
]. The positive
effect of PSE on academic performance may relate to additional learning resources and
opportunities outside the school walls. However, intensive PSE participation did not
Int. J. Environ. Res. Public Health 2021,18, 1222. https://doi.org/10.3390/ijerph18031222 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 1222 2 of 18
guarantee success in school achievement. Students showed decreased school performance
and felt sleepy during the daytime when they spent over 10–12 h per week participating in
after-school studying [
12
,
13
]. Moreover, not many empirical studies address the potential
negative “side effect” of PSE on young people’s mental health. Depression is one of the
fastest-growing illnesses among young people and is found to be one of the most common
reasons contributing to adolescent suicide [
24
,
25
], anxiety and stress [
26
,
27
], and school
failure among adolescents [
28
,
29
]. It is imperative to understand the potential impacts of
PSE participation on adolescents’ mental health.
Is there a trade-off between mental health and school achievement? Or is this trade-off
conditional on specific PSE participation patterns? There are even fewer studies investi-
gating the relationship between PSE and adolescents’ mental health [
11
,
30
]. In light of
the rising popularity of PSE participation worldwide, an empirical study of the effects of
various PSE participation patterns on mental health and academic achievement in Taiwan,
where the prevalence and intensity of PSE participation are high, would help to fill the gap
in knowledge on the short- and long-term impacts of PSE involvement.
The goal of this study is threefold. First, we identify the typical patterns of students’
PSE participation from 7th–9th grade in Taiwan. Second, we assess whether PSE partic-
ipants outperform non-participants in their entrance examination across different types
of PSE involvement. Third, we also analyze PSE patterns’ effects on students’ depression
symptoms in later adolescence (11th grade), controlling for early school achievement and
mental health. In short, we focus not only on the various patterns of PSE participation but
also on the impacts of these patterns on the correlated outcomes of school achievement
and depression.
2. Materials and Methods
2.1. Data and Procedure
The present study uses recently released data gathered by the Taiwan Upper Secondary
Database (TUSD) during the 2014 academic year. The TUSD conducted an annual census of
first-year senior high school students, with the Ministry of Education’s support, since 2001
when students just enrolled in school. Since 2002, the TUSD also conducted a follow-
up census every year when students were in the second semester of their second high-
school year. A significant portion of information gathered from the first-year student’s
census is about students’ junior high schooling experiences. In 2014, the census gathered
extensive information about students’ PSE participation and cram schooling experiences.
The response rate of the 2014 census nears 91%. Recently, the TUSD released a randomly
selected sample of the 2014 census and its 2015 follow-up census. The sample size is 18,450,
which is about 8% of the census data. The present study focuses on those who attended
public junior high school and excludes vocational high, private high, and five-year junior
college students. We generate missing flags for several covariates, such as parent education,
parent occupation, and family structure, to control the effects of missing cases. The final
analytical sample size is 7708.
2.2. Variables and Measurement
2.2.1. Dependent Variables
The first outcome of interest is self-reported scores from the high school entrance
examination. The examination score is the summed score of six test subjects, including
Chinese, English, Mathematics, Sciences, Social Studies, and Writing. It ranges between 1
and 37, with a mean of 20.55 and a standard deviation of 7.72. Even though the outcome
is self-reported examination scores, the percentile distribution of the self-reported scores
correlates strongly with the distribution reported by the Research Center for Psychological
and Educational Testing, which is responsible for designing the examination. Hence,
the student’s self-reported entrance examination score is a valid measurement of the school
achievement outcome in high school transition.
Int. J. Environ. Res. Public Health 2021,18, 1222 3 of 18
The second outcome of interest is depression symptoms. Depression symptoms are
common during adolescence. Symptoms tend to affect students negatively in terms of how
they feel and how they act in school. The TUSD survey asked 11th graders about their
mental health in the past three months, including (1) I feel like a failure in my life; (2) I feel
disappointed in myself; (3) I feel happy; (4) I feel too tired to do anything; (5) I have trouble
keeping my mind focused. The five questions are on a scale from 1 to 5. The Cronbach’s
alpha is 0.83. These items are similar to the Taiwanese Depression Questionnaire [
31
,
32
].
We use the 2-parameter logistic (2PL) item response theory (IRT) model to generate an IRT
score for polytomous response data.
2.2.2. Key Independent Variables
To identify individual differences in PSE participation experiences between 7th and 9th
grade, we code the participation in each of the six semesters dichotomously and apply the
latent class analysis (LCA). Based on the LCA, we identify five PSE participation patterns
from 7th to 9th grade. We name these five patterns as always-takers, early adopters,
late adopters, dropouts, and explorers. We report the LCA results and class identification
index in Appendix A. The decision to choose five patterns as the best fitting solution
among alternatives is based on indices of entropy, the Akaike information criterion (AIC),
the Bayesian information criterion (BIC), and the Vuong-Lo-Mendell-Rubin likelihood
ratio test [
33
,
34
]. We also label those who never attended cram schools in junior high
as never-takers. The respective count of these six patterns of PSE participation during
junior high school are as follows: never-takers, 1888 (24.47%); always-takers, 3659 (47.41%);
early adopters, 554 (7.18%); dropout, 534 (7.08%), late adopters, 324 (4.20%) and explorers,
749 (9.71%).
Figure 1shows the estimated probability of participating in PSE in each semester
across five patterns. Always-takers are those who attended cram schools for almost all of
six semesters. Early adopters are students who tended to start attending PSE in the second
semester as 7th graders. Late adopters are students who began PSE in the 9th grade. Dropouts
started attending PSE at the beginning of junior high and then drop out of cram schooling
in the 8th grade or 9th grade. Explorers only participate in cram schooling for one semester,
which could occur during any semester.
Int. J. Environ. Res. Public Health 2021, 18, x 4 of 15
Figure 1. Estimated probability of participating in private supplementary education (PSE) across semesters.
2.2.3. Covariates
All covariates used to estimate the probabilities of PSE participation patterns and
regression analyses are based on the census in the 2014 school year. Demographics and
family background variables include the students’ gender, race/ethnicity (Minnan/Main-
lander, Aborigine, other), and the number of siblings at home. Student’s characteristics
and school environment variables include subject-specific self-efficacy, 9th-grade school
ranking, happiness in learning, teacher quality, and classroom climate in junior high.
Subject-specific self-efficacy is measured by the students’ self-report on whether they
are confident at five academic subjects (Chinese, English, Mathematics, Sciences, and So-
cial Studies) in junior high. We generate a composite score, which has the Cronbach’s α
as 0.86. The 9th-grade school ranking is measured by a self-reported school ranking, rang-
ing from 1–5. Both measures are taken as a proxy for school achievement prior to taking
the high school entrance exam. Happiness in learning was measured by asking students
whether they felt happy with their learning during junior high, ranging from 1–4; a proxy
for mental health in junior high.
Teacher quality or instruction in junior high school was measured by the extent to
which students agreed with the following five statements: “How many teachers in your
junior high school (1) provide different instructions based on students’ ability; (2) evaluate
students’ performance based on other activities (e.g., projects or group discussion); (3) use
diverse instructional methods (e.g., projects, group discussions, experiments, experiences
or teamwork to accomplish homework); (4) care about your learning (e.g., encourage you
or help with problem-solving in learning); (5) teach well or inspire you a lot in learning.”
The five questions are on a scale from 1 to 4. The Cronbach’s α is 0.84.
Junior high school climate for learning is measured by the extent to which students
agreed with the following statements: “how often the lesson cannot be finished as sched-
uled”, “how often students skip school”, “student overall learning climate in school”, and
“how often bullying behavior happened in school” on a scale from 1 to 4 with higher
scores representing a friendly school climate for learning. The Cronbach’s α is 0.70.
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
7th grade _Fall 7th grade
Spring
8th grade Fall 8th grade
Spring
9th grade Fall 9th grade
Spring
class-1:Always-taker class-2: Early adopter
class-3: Dropout class-4: Later adopter
class-5: Explorer
Figure 1.
Estimated probability of participating in private supplementary education (PSE)
across semesters.
Int. J. Environ. Res. Public Health 2021,18, 1222 4 of 18
2.2.3. Covariates
All covariates used to estimate the probabilities of PSE participation patterns and re-
gression analyses are based on the census in the 2014 school year. Demographics and family
background variables include the students’ gender, race/ethnicity (Minnan/Mainlander,
Aborigine, other), and the number of siblings at home. Student’s characteristics and
school environment variables include subject-specific self-efficacy, 9th-grade school rank-
ing, happiness in learning, teacher quality, and classroom climate in junior high.
Subject-specific self-efficacy is measured by the students’ self-report on whether they
are confident at five academic subjects (Chinese, English, Mathematics, Sciences, and Social
Studies) in junior high. We generate a composite score, which has the Cronbach’s
α
as 0.86.
The 9th-grade school ranking is measured by a self-reported school ranking, ranging from
1–5. Both measures are taken as a proxy for school achievement prior to taking the high
school entrance exam. Happiness in learning was measured by asking students whether
they felt happy with their learning during junior high, ranging from 1–4; a proxy for mental
health in junior high.
Teacher quality or instruction in junior high school was measured by the extent to
which students agreed with the following five statements: “How many teachers in your
junior high school (1) provide different instructions based on students’ ability; (2) evaluate
students’ performance based on other activities (e.g., projects or group discussion); (3) use
diverse instructional methods (e.g., projects, group discussions, experiments, experiences
or teamwork to accomplish homework); (4) care about your learning (e.g., encourage you
or help with problem-solving in learning); (5) teach well or inspire you a lot in learning”.
The five questions are on a scale from 1 to 4. The Cronbach’s αis 0.84.
Junior high school climate for learning is measured by the extent to which students
agreed with the following statements: “how often the lesson cannot be finished as sched-
uled”, “how often students skip school”, “student overall learning climate in school”,
and “how often bullying behavior happened in school” on a scale from 1 to 4 with higher
scores representing a friendly school climate for learning. The Cronbach’s αis 0.70.
The family structure includes five types: (1) intact family—living with both bio-
logical parents; (2) step-family—living with the birth mother and the male guardian or
the biological father and the female guardian; (3) single-family—residing in the birth-
mother-only or the birth-father-only family; and (4) grand-parent guardian, and (5) other
guardians/relatives—living with relatives or other non-biological guardians. Parents’ oc-
cupation is categorized into six types: (1) farmer or non-technical worker, (2) technical
worker, (3) service worker, (4) semi-professional worker, (5) professional worker, and (6)
full-time military personnel. The highest parental education is coded into five levels. Either
the father’s or mother ’s education is categorized into five groups, ranging from “1 = less
than high school” to “5 = college-graduated and beyond”. We then use the highest level of
education derived from either the mother or father to represent parents’ education. If either
of these variables were missing, we substituted either the father’s or mother ’s highest
education to reduce the missing cases.
2.3. Analytical Strategy
This study combines the latent class analysis (LCA), a seemingly unrelated regression
(SUR), and the inverse-probability-of-treatment weighting (IPTW) approach to assess the
various patterns of PSE participation on students’ entrance examination and depression
symptoms in 11th grade. Our analytic strategies are as follows. First, we report the LCA
results in Figure 1, which shows the best fitting solution of class identification in five classes
(see Appendix A). Second, we provide the descriptive results and the mean difference test
compared to the reference group of never-taker in Table 1. Third, we use logistic regression
to calculate the inverse probability treatment weighting (IPTW) for the average treatment
effect (ATE) and the average treatment effect on the treated (ATT) for each PSE pattern
compared to the never-takers [
35
]. With IPTW weighting, we obtained a pseudo-population
where covariates are balanced between the treatment and the control group. We then fit the
Int. J. Environ. Res. Public Health 2021,18, 1222 5 of 18
seemingly unrelated regression model (SUR) with a maximum likelihood estimation of the
effects of PSE participation in junior high on two correlated outcomes, high school entrance
examination and depressive symptoms in 11th grade (see Table 3 and Table 4). The SUR
model is a regression in which two outcomes can be predicted by a set of predictors and
accounts for correlations between the residuals, possibly unobserved variables, from the
individual regressions. We used the user-written Stata package “mysureg” [
36
]. Figure 2
shows the research framework and the key variables in the seemingly unrelated regression
(SUR) model. We also offer the simplified SURG equation in the following.
y1(Depression symptoms)
y2(Entrance examination)=X10
0X2 β1
β2+ε1
ε2(1)
Int. J. Environ. Res. Public Health 2021, 18, x 6 of 15
C
Grade 7
Fall
Grade 7
Spring
Grade 8
Fall
Grade 8
Spring
Grade 9
Fall
Grade 9
Spring
Entrance
examination
overall score
Depression
IRT score in
11th grade
Covariates:
9th grade school ranking
Happy to learn in junior high
Subject efficacy in junior high
Family characteristics
Junior high school characteristics
Figure 2. The Research Framework.
3. Results
Table 1 presents descriptive statistics across the patterns of PSE participation. Those
who are the always-takers during junior high have a clearly advantaged family, school,
and educational background and resources. Compared to never-takers, always-takers,
early-adopters, and late-adopters tend to have parents with a semi-professional or profes-
sional job, at least some college education, middle-class family income with an intact fam-
ily. The proportion of living in single families and grand-parent families is similar among
dropouts, explorers, and never-takers. However, dropouts and explorers tend to have par-
ents with some college education and middle-class family income. Concerning school
achievement, PSE participants, regardless of their patterns, have higher entrance exami-
nation scores, subject efficacy, and 9th-grade school ranking in junior high than the never-
takers. PSE participants also have a smaller number of siblings and a higher family income
level than the never-takers.
As for mental health, Table 1 also shows that the always-takers have significantly
higher depression symptoms in high school than the never-takers. Students who are early
adopters report a lower level of happiness in learning than never-takers. Lastly, all PSE
participants experienced a lower school climate level for learning in terms of school char-
acteristics, but only early adopters reported significantly lower teacher quality in junior
high. In short, various PSE participation patterns differ in terms of family socioeconomic
background, family configuration, and schooling climate experience in junior high. Stu-
dents with more advantaged family backgrounds tend to participate in PSE for longer or
with stability. However, they also tend not to satisfy with their schooling environment.
Since these family and school factors are confounders for the observed differences in aca-
demic performance and mental health between PSE participation patterns, we need to
consider these background differences before we can attribute the differences in outcomes
to PSE participation patterns.
Table 1. Descriptive statistics across the patterns of PSE participation.
Never-
Taker Always-Taker Early
Adopter Dropout Later
Adopter Explorer
All variabels 1 Mean/(SD)
3 Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD)
Entrance-exam score 6.59 13.85 *** 2 13.30 *** 9.41 *** 13.89 *** 10.66 ***
(6.79) (7.17) (6.92) (7.22) (7.75) (8.20)
Depression in 11th grade −0.03 0.03 * 0.04 0.05 0.07 0.04
(0.95) (0.82) (0.77) (0.86) (0.81) (0.73)
Subject efficacy in junior high 11.51 13.03 *** 12.99 *** 12.22 *** 12.86 *** 12.22 ***
(2.68) (2.17) (2.06) (2.28) (2.34) (2.70)
9th grade academic ranking 3.05 4.08 *** 3.98 *** 3.46 *** 3.96 *** 3.57 ***
(1.28) (0.95) (0.99) (1.15) (1.01) (1.28)
Figure 2. The Research Framework.
The covariance matrix is
Varε1
ε2=σ11
σ12 σ22 , correlation residual (σ12)
3. Results
Table 1presents descriptive statistics across the patterns of PSE participation. Those who
are the always-takers during junior high have a clearly advantaged family, school, and ed-
ucational background and resources. Compared to never-takers, always-takers, early-
adopters, and late-adopters tend to have parents with a semi-professional or professional
job, at least some college education, middle-class family income with an intact family.
The proportion of living in single families and grand-parent families is similar among
dropouts, explorers, and never-takers. However, dropouts and explorers tend to have
parents with some college education and middle-class family income. Concerning school
achievement, PSE participants, regardless of their patterns, have higher entrance examina-
tion scores, subject efficacy, and 9th-grade school ranking in junior high than the never-
takers. PSE participants also have a smaller number of siblings and a higher family income
level than the never-takers.
Int. J. Environ. Res. Public Health 2021,18, 1222 6 of 18
Table 1. Descriptive statistics across the patterns of PSE participation.
Never-Taker Always-Taker Early Adopter Dropout Later Adopter Explorer
All variabels 1Mean/(SD) 3Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD)
Entrance-exam score 6.59 13.85 ***,2 13.30 *** 9.41 *** 13.89 *** 10.66 ***
(6.79) (7.17) (6.92) (7.22) (7.75) (8.20)
Depression in 11th grade −0.03 0.03 * 0.04 0.05 0.07 0.04
(0.95) (0.82) (0.77) (0.86) (0.81) (0.73)
Subject efficacy in junior high 11.51 13.03 *** 12.99 *** 12.22 *** 12.86 *** 12.22 ***
(2.68) (2.17) (2.06) (2.28) (2.34) (2.70)
9th grade academic ranking 3.05 4.08 *** 3.98 *** 3.46 *** 3.96 *** 3.57 ***
(1.28) (0.95) (0.99) (1.15) (1.01) (1.28)
Happiness in learning 2.98 2.94 2.87 ** 2.98 2.92 2.95
(0.76) (0.74) (0.72) (0.70) (0.75) (0.77)
Number of siblings 1.50 1.24 *** 1.26 *** 1.32 *** 1.24 *** 1.35 ***
(1.02) (0.80) (0.81) (0.88) (0.84) (0.89)
School climate 0.09 −0.02 *** −0.02 *** 0.00 ** −0.04 ** 0.02 *
(0.73) (0.76) (0.73) (0.74) (0.77) (0.79)
Teacher quality 0.10 0.09 0.01 * 0.04 0.14 0.08
(0.89) (0.83) (0.83) (0.88) (0.86) (0.90)
Family income 3.13 3.48 *** 3.43 *** 3.34 *** 3.44 *** 3.31 ***
(0.74) (0.62) (0.70) (0.70) (0.68) (0.74)
Female 0.41 0.49 *** 0.48 ** 0.49 ** 0.48 * 0.44
Ethnicity
Minnan/Mainlander 0.91 0.97 *** 0.96 *** 0.95 ** 0.95 * 0.93
Aborigines 0.07 0.01 *** 0.01 *** 0.03 *** 0.03 ** 0.04 **
Others 0.02 0.01 ** 0.02 0.02 0.01 0.02
Parents’ occupation
Farmer 0.06 0.03 *** 0.02 *** 0.04 0.01 *** 0.03 **
Technical 0.25 0.13 *** 0.11 *** 0.17 *** 0.12 *** 0.14 ***
Salary manner 0.26 0.21 *** 0.17 *** 0.25 0.20 * 0.24
Semi-professional 0.23 0.32 *** 0.34 *** 0.31 *** 0.29 * 0.26
Professional 0.20 0.31 *** 0.35 *** 0.23 0.37 *** 0.31 ***
Others: Military 0.01 0.01 0.00 0.00 0.00 0.01
Int. J. Environ. Res. Public Health 2021,18, 1222 7 of 18
Table 1. Cont.
Never-Taker Always-Taker Early Adopter Dropout Later Adopter Explorer
All variabels 1Mean/(SD) 3Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD) Mean/(SD)
Parents’ highest education
Junior high or lower 0.14 0.04 *** 0.06 *** 0.08 *** 0.02 *** 0.07 ***
High school 0.49 0.37 *** 0.33 *** 0.48 0.27 *** 0.39 ***
Some college 0.24 0.31 *** 0.29 * 0.27 0.31 * 0.27
College 0.09 0.15 *** 0.17 *** 0.12 * 0.19 *** 0.16 ***
Beyond college 0.05 0.12 *** 0.15 *** 0.06 0.21 *** 0.12 ***
Family structure
Intact family 0.70 0.82 *** 0.78 *** 0.71 0.81 *** 0.70
Step-family 0.02 0.01 ** 0.01 0.03 0.01 0.01
Single family 0.17 0.10 *** 0.13 * 0.15 0.10 ** 0.16
Grand-parent guardians 0.03 0.01 *** 0.02 0.03 0.01 * 0.02
Forster-parent 0.01 0.00 *** 0.00 * 0.00 0.01 0.01
Living with other relatives 0.06 0.05 0.06 0.08 0.06 0.09 **
1
All variables except institutional variables are from 2014 survey data collection.
2
Two-tailed t-tests and Pearson chi-square tests were conducted for continuous and categorical variables and ***, **, * denoted
significant differences compared with never-takers under p< 0.001 p< 0.01, p< 0.05. 3Numbers in parentheses are standard deviations.
Int. J. Environ. Res. Public Health 2021,18, 1222 8 of 18
As for mental health, Table 1also shows that the always-takers have significantly
higher depression symptoms in high school than the never-takers. Students who are
early adopters report a lower level of happiness in learning than never-takers. Lastly,
all PSE participants experienced a lower school climate level for learning in terms of
school characteristics, but only early adopters reported significantly lower teacher quality
in junior high. In short, various PSE participation patterns differ in terms of family
socioeconomic background, family configuration, and schooling climate experience in
junior high. Students with more advantaged family backgrounds tend to participate in
PSE for longer or with stability. However, they also tend not to satisfy with their schooling
environment. Since these family and school factors are confounders for the observed
differences in academic performance and mental health between PSE participation patterns,
we need to consider these background differences before we can attribute the differences
in outcomes to PSE participation patterns.
To examine PSE participation’s heterogeneous effects on academic achievement and
mental health, we used a logistic regression to estimate each PSE pattern’s propensity score
with the never-taker as the contrast first. Table 2shows the results of logistic regression.
Consistent with the descriptive findings, being a female, family income, parental education
and occupation are all positively associated with the likelihood of being always-takers,
early adopters, and late adopters. Those living in a non-intact family, having more siblings,
and experiencing a good school climate tend to have a lower likelihood of PSE participation.
It is worth noting that living in single or grand-parent families or having more siblings tend
to reduce the possibility of being an early adopter and late adopter in PSE. Our logistic
regression also confirms that students with an advantaged family background are more
likely to participate in PSE. However, different PSE participation patterns also relate to
prior school achievement, parents’ education level, occupation, and family structure.
After obtaining the propensity score of PSE participation, we generated the inverse-
probability-of-treatment weights (IPTW) for each PSE pattern and conducted a balance
check between participants and the never-taker. We use two tests to evaluate the balancing
results using the IPTW approach [
37
,
38
]. The first was to calculate the covariates’ stan-
dardized mean differences between the treatment group (any PSE participation pattern)
and the control group (the never-takers). After weighting, the standardized means were
between
−
0.08 and +0.09, markedly smaller than the acceptable range of
−
0.1 and +0.1
after weighing. The second method uses the model-adjusted difference in the ratio of
variances between the treatment and control groups. Rubin (2001) suggests that the range
of difference should be between 0.5 and 2.0. The ranges found in our analyses are between
0.8 and 1.2. Most of them are near 1.0. The prior covariates are not statistically significant
between PSE participants’ patterns and the never-takers after IPTW weighting.
To estimate PSE participation’s treatment effect, we use the seemingly unrelated
regression model (SUR) with maximum likelihood estimation on two possibly correlated
outcome variables—entrance examination in the transition into high school and depression
symptoms in 11th grade. Table 3reports the average treatment effect for the treated (ATT)
using the IPTW weighted SUR model. For example, the ATT estimated for the always-
takers group refers to the difference in the average effect of PSE participation for students
who participated in PSE almost all six semesters during junior high school as opposed to the
hypothetical (counterfactual) situation if they were never-takers. The findings show some
common trends across PSE patterns and suggest that always-takers and dropouts increase
their depression symptoms on average by 0.067 (p< 0.05) and 0.089 (p< 0.05) IRT score.
However, they also increase their overall score of entrance examination by 1.942
(p< 0.001
)
and 0.767 (p< 0.001). Additionally, early adopters, late adopters, and explorers also increase
their overall score of entrance examination by 1.590 (p< 0.001), 1.716 (
p< 0.001
), and 1.223
(p< 0.001), but they have a similar level of depression symptoms as never-takers in their
11th grade. At the bottom panel of Table 3, the correlation between the residuals of the
two outcomes is significant at p< 0.01 for always-takers, dropouts, and explorers. In other
words, there could be some other unobserved factors linking the two outcomes.
Int. J. Environ. Res. Public Health 2021,18, 1222 9 of 18
Table 2. Logistic regression predicting the propensity of PSE participation patterns in junior high.
Always-Taker Early Adopter Dropout Later Adopter Explorer
b/se b/se b/se b/se b/se
Female 0.458 ***,1,2 0.401 *** 0.435 *** 0.361 ** 0.189 *
(0.065) (0.107) (0.104) (0.134) (0.094)
Ethnicity (Ref. Minnan/Mainlander)
Aborigines −1.418 *** −1.273 ** −0.891 ** −0.299 −0.210
(0.188) (0.401) (0.302) (0.352) (0.217)
Others −0.553 −0.352 0.037 −0.588 −0.296
(0.318) (0.474) (0.449) (0.680) (0.430)
Family income 0.575 *** 0.388 *** 0.397 *** 0.305 ** 0.242 ***
(0.050) (0.082) (0.079) (0.103) (0.069)
Parents’ Highest Education
High school (Ref. Junior high or lower) 0.784 *** 0.326 0.380 1.331 ** 0.484 *
(0.127) (0.226) (0.196) (0.469) (0.190)
Some college 1.051 *** 0.698 ** 0.402 1.989 *** 0.666 ***
(0.135) (0.233) (0.211) (0.472) (0.201)
College 1.125 *** 0.934 *** 0.441 2.310 *** 0.967 ***
(0.157) (0.257) (0.246) (0.488) (0.224)
Beyond college 1.354 *** 1.260 *** 0.312 2.972 *** 1.223 ***
(0.179) (0.278) (0.297) (0.499) (0.249)
Family structure (Ref. Intact family)
Step-family −0.921 *** −0.553 0.311 −0.972 −0.702
(0.259) (0.435) (0.323) (0.621) (0.402)
Single family −0.623 *** −0.200 −0.148 −0.706 ** 0.046
(0.107) (0.171) (0.169) (0.252) (0.144)
Grand-parent guardians −0.944 *** −0.856 * −0.120 −1.573 * −0.288
(0.221) (0.426) (0.316) (0.738) (0.312)
Forster-parent −0.737 −1.462 −0.555 −0.169 0.042
(0.446) (1.083) (0.783) (0.817) (0.530)
Living with other relatives or missing flag −0.408 ** −0.211 0.280 −0.361 0.287
(0.137) (0.222) (0.200) (0.275) (0.176)
Parent Occupation (Ref. Farmer)
Technical 0.275 0.066 −0.101 −0.410 0.012
(0.220) (0.436) (0.331) (0.472) (0.330)
Salary manner 0.372 0.382 −0.084 −0.196 0.160
(0.195) (0.377) (0.286) (0.385) (0.285)
Int. J. Environ. Res. Public Health 2021,18, 1222 10 of 18
Table 2. Cont.
Always-Taker Early Adopter Dropout Later Adopter Explorer
b/se b/se b/se b/se b/se
Semi-professional 0.775 *** 0.735 0.193 0.362 0.540
(0.201) (0.383) (0.296) (0.387) (0.292)
Professional 0.973 *** 1.181 ** 0.294 0.154 0.689 *
(0.199) (0.377) (0.294) (0.387) (0.289)
Others: Military 0.834 *** 1.068 ** 0.037 0.314 0.668 *
(0.205) (0.382) (0.306) (0.386) (0.294)
Number of siblings −0.274 *** −0.175 ** −0.113 * −0.216 ** −0.079
(0.036) (0.062) (0.057) (0.078) (0.051)
School climate for learning −0.261 *** −0.186 * −0.165 * −0.269 ** −0.105
(0.046) (0.077) (0.075) (0.093) (0.066)
Teacher quality 0.066 −0.086 −0.026 0.124 −0.007
(0.040) (0.066) (0.063) (0.081) (0.056)
Constant −2.416 *** −3.589 *** −2.943 *** −4.331 *** −2.690 ***
(0.266) (0.486) (0.402) (0.650) (0.379)
1We report regression coefficients. 2*** p< 0.001, ** p< 0.01, * p< 0.05.
Table 3.
Estimation of average treatment effect on the treated (ATT) using inverse-probability-of-treatment weighting (IPTW) weighted seemingly unrelated regression (SUR) models by
PSE Participation.
Always-Taker Early-Adopter Dropout Late-Adopter Explorer
Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam
b/se b/se b/se b/se b/se b/se b/se b/se b/se b/se
Always-taker vs. Never-taker 10.067 *,2 1.942 ***
(0.032) (0.220)
Early-adopter vs. Never-taker 0.048 1.590 ***
(0.045) (0.305)
Dropout vs. Never-taker 0.089 * 0.767 **
(0.045) (0.268)
Late-adopter vs. Never-taker 0.067 1.716 ***
(0.055) (0.398)
Explorer vs. Never-taker 0.048 1.223 ***
(0.036) (0.261)
Int. J. Environ. Res. Public Health 2021,18, 1222 11 of 18
Table 3. Cont.
Always-Taker Early-Adopter Dropout Late-Adopter Explorer
Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam
b/se b/se b/se b/se b/se b/se b/se b/se b/se b/se
Subjects efficacy in junior high −0.039 *** 0.406 *** −0.051 *** 0.475 *** −0.031 ** 0.515 *** −0.042 ** 0.431 *** −0.038 *** 0.346 ***
(0.008) (0.069) (0.011) (0.092) (0.011) (0.073) (0.013) (0.121) (0.009) (0.075)
Happiness in learning −0.159 *** −0.153 *** −0.161 *** −0.182 *** −0.112 ***
(0.025) (0.037) (0.037) (0.042) (0.031)
9th grade academic ranking 0.026 3.223 *** 0.054 * 3.144 *** −0.006 2.850 *** 0.011 3.322 *** 0.025 3.227 ***
(0.017) (0.134) (0.023) (0.167) (0.022) (0.145) (0.028) (0.222) (0.019) (0.143)
Female 0.036 0.108 −0.022 −0.544 0.048 0.415 0.099 0.233 0.030 0.030
(0.031) (0.198) (0.043) (0.285) (0.045) (0.278) (0.054) (0.394) (0.037) (0.266)
Aborigines −0.089 −2.538 *** −0.049 −3.688 *** −0.185 −1.296 −0.252 * −3.000 *** −0.062 −2.648 ***
(0.086) (0.438) (0.134) (0.815) (0.117) (0.857) (0.111) (0.629) (0.081) (0.592)
Others −0.133 3.014 −0.048 2.508 −0.006 −0.027 −0.095 5.989 ** −0.108 0.210
(0.191) (2.354) (0.233) (1.816) (0.203) (1.181) (0.244) (2.179) (0.216) (1.570)
Family income −0.083 ** 0.003 −0.089 ** 0.037 −0.088 * −0.009 −0.043 0.546 −0.076 ** 0.073
(0.025) (0.160) (0.034) (0.228) (0.035) (0.194) (0.042) (0.280) (0.027) (0.202)
Parents’ highest education
High school (Ref. Junior high or lower)
−0.043 0.250 0.025 0.094 −0.277 ** 0.781 −0.094 −1.264 −0.038 −0.423
(0.059) (0.320) (0.088) (0.491) (0.087) (0.470) (0.170) (2.727) (0.080) (0.477)
Some college 0.029 2.325 *** 0.065 2.289 *** −0.150 3.014 *** −0.180 0.573 0.021 1.686 **
(0.062) (0.352) (0.089) (0.538) (0.093) (0.529) (0.171) (2.750) (0.085) (0.519)
Normal University 0.154 * 3.579 *** 0.171 3.058 *** −0.054 3.237 *** −0.033 1.715 0.158+ 2.992 ***
(0.071) (0.421) (0.101) (0.613) (0.113) (0.601) (0.180) (2.781) (0.094) (0.610)
Beyond college 0.028 5.499 *** 0.108 5.510 *** −0.038 6.188 *** 0.057 3.445 0.063 5.450 ***
(0.084) (0.514) (0.115) (0.693) (0.140) (0.846) (0.186) (2.827) (0.107) (0.732)
Family structure
Step-family family) 0.215 −2.492 *** 0.086 −0.030 0.042 −2.080 ** −0.272 −2.745 −0.009 −1.720 *
(Ref. Intact family) (0.112) (0.672) (0.104) (1.524) (0.150) (0.736) (0.184) (2.310) (0.154) (0.848)
Single family 0.063 −1.104 *** −0.051 −1.740 *** 0.034 −1.210 ** 0.127 −1.779 * 0.014 −0.805
(0.048) (0.333) (0.064) (0.470) (0.078) (0.414) (0.091) (0.776) (0.053) (0.419)
Grand-parent guardians −0.204 * −1.958 *** 0.177 −3.261 *** −0.138 −1.685 * −0.366 −1.990 0.060 −2.682 ***
(0.101) (0.562) (0.182) (0.790) (0.141) (0.665) (0.496) (2.692) (0.146) (0.705)
Forster-parent 0.390 * −1.411 −0.365 −1.305 −0.017 2.588 0.346 −2.756 0.596 * −0.657
(0.169) (1.147) (0.522) (0.961) (0.279) (1.788) (0.225) (1.487) (0.280) (0.852)
Living with other relatives 0.083 −0.755 0.100 −1.601 * 0.116 −0.583 −0.040 −0.877 0.060 0.032
Or missing (0.063) (0.440) (0.079) (0.624) (0.079) (0.551) (0.100) (0.873) (0.073) (0.569)
Int. J. Environ. Res. Public Health 2021,18, 1222 12 of 18
Table 3. Cont.
Always-Taker Early-Adopter Dropout Late-Adopter Explorer
Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam
b/se b/se b/se b/se b/se b/se b/se b/se b/se b/se
Parent Occupation
Technical 0.074 −1.205 * −0.268 −1.520 0.006 −0.969 −0.215 −1.134 0.012 −1.503
(0.094) (0.581) (0.162) (1.218) (0.131) (0.734) (0.212) (1.273) (0.104) (0.835)
Salary manner 0.088 −0.175 −0.207 −0.598 0.166 0.177 −0.144 −0.081 0.077 0.035
(0.083) (0.511) (0.143) (1.051) (0.095) (0.530) (0.192) (1.014) (0.074) (0.728)
Semi-professional 0.170 * 0.463 −0.163 0.006 0.135 0.058 −0.176 0.345 0.172 * 0.709
(0.085) (0.533) (0.144) (1.079) (0.101) (0.591) (0.193) (1.047) (0.079) (0.763)
Professional 0.118 0.093 −0.210 −0.918 0.205 * 0.477 −0.181 0.178 0.105 0.309
(0.085) (0.530) (0.144) (1.059) (0.098) (0.582) (0.192) (1.052) (0.078) (0.757)
Others: Military 0.162 1.065 −0.119 0.229 0.183 1.019 −0.154 1.309 0.191 * 1.333
(0.087) (0.549) (0.146) (1.079) (0.104) (0.594) (0.193) (1.012) (0.083) (0.779)
Number of siblings −0.001 −0.662 *** 0.025 −0.894 *** −0.018 −0.349 * 0.012 −0.819 *** −0.012 −0.360**
(0.017) (0.123) (0.025) (0.168) (0.022) (0.138) (0.031) (0.242) (0.020) (0.133)
School climate −0.085 *** −0.236 −0.086 * −0.383 −0.116 ** −0.797 *** −0.081 −0.534 −0.085 ** −0.386
(0.025) (0.177) (0.038) (0.252) (0.036) (0.217) (0.042) (0.310) (0.030) (0.214)
Teacher quality −0.001 −0.020 −0.014 −0.191 −0.021 0.212 −0.013 0.082 0.009 0.007
(0.020) (0.127) (0.027) (0.177) (0.030) (0.165) (0.034) (0.246) (0.024) (0.166)
Constant 0.956 *** −7.873 *** 1.267 *** −6.957 *** 1.150 *** −9.071 *** 1.355 *** −8.523 ** 0.791 *** −7.544 ***
(0.161) (0.954) (0.237) (1.573) (0.207) (1.121) (0.317) (2.850) (0.173) (1.228)
σ11 (Depression) 0.718 *** 0.676 *** 0.756 *** 0.682 *** 0.660 ***
(0.019) (0.026) (0.029) (0.033) (0.025)
σ22 (Entrance exam) 28.798 *** 26.470 *** 25.999 *** 31.494 *** 28.597 ***
(0.869) (1.135) (1.075) (1.634) (1.209)
σ12 (Depression*Entrance exam) 0.253 ** 0.208+ 0.407 *** 0.278+ 0.262 **
(0.084) (0.112) (0.108) (0.148) (0.102)
σ12 correlation residual 0.055 * 0.049 0.091 * 0.0601 0.060 *
1We run the SUR model by PSE participation patterns. All SUR models compared to students who never participate in PSE (Never-taker). 2*** p< 0.001, ** p< 0.01, * p< 0.05.
Int. J. Environ. Res. Public Health 2021,18, 1222 13 of 18
As for the effects of covariates, students had lower depression symptoms in the 11th
grade when they were happy in learning in junior high, living in a higher family income
household, felt confident in their subject-specific learning, and had a supportive school
climate. Students’ parents with a 4-year university degree or semi-professional job in-
crease their depression symptoms. Concerning school achievement, students improved
their scores of entrance examination when they had a higher subject-specific efficacy,
9th-grade
school academic ranking, and with parents having at least a high school educa-
tion.
Non-intact
family structure and a larger number of siblings tend to reduce students’
scores in the entrance examination.
Table 4shows the results of the average treatment effect of SUR with IPTW weighting.
ATE estimates the average treatment effect for each PSE pattern if all students participated
in PSE. Specifically, if all students are always-takers, their depression symptoms IRT score
would increase by 0.068 and their overall score of entrance examination would increase
by 2.071 at the same time. The results are similar to those found for the treated (Table 3),
with two exceptions. First, participating in PSE in junior high correlates with increased
11th graders’ depression symptoms among always-takers, dropouts, and late adopters.
Second, the correlation between the two outcomes’ residuals is significant for always-takers,
early adopters, dropouts, and explorers. As for covariate effects, we found a similar pattern
as we described in Table 3. Therefore, we report only the main results of interest in Table 4.
Table 4. Estimation of average treatment effect (ATE) using IPTW weighted SUR models by PSE participation.
Always-Taker 1Early-Adopter Dropout Late-Adopter Explorer
Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam Depression Entrance
Exam
b/se b/se b/se b/se b/se b/se b/se b/se b/se b/se
Always-taker 0.068 *,2 2.071 ***
vs. Never-taker (0.031) (0.205)
Early-adopter 0.058 1.922 ***
vs. Never-taker (0.048) (0.284)
Dropout 0.104 * 0.891 **
vs. Never-taker (0.047) (0.272)
Late-adopter 0.139 * 2.238 ***
vs. Never-taker (0.062) (0.489)
Explorer 0.051 1.164 ***
vs. Never-taker (0.036) (0.233)
σ11 0.735 *** 0.690 *** 0.766 *** 0.708 *** 0.674 ***
(0.018) (0.026) (0.030) (0.036) (0.026)
σ22 28.211 *** 23.550 *** 25.064 *** 30.744 *** 25.867 ***
(0.819) (0.940) (1.068) (2.747) (1.044)
σ12 0.252 ** 0.229 * 0.430 *** 0.015 0.326 ***
(0.079) (0.100) (0.104) (0.198) (0.096)
σ12 0.055 * 0.056 * 0.098 * 0.003 0.078 *
1
We run the SUR model by PSE participation patterns. All SUR models compared to students who never participate in PSE (Never-taker).
2*** p< 0.001, ** p< 0.01, * p< 0.05.
4. Discussion
The current study utilizes a person-centered approach to better understand the asso-
ciation between PSE participation in junior high, high school entrance examination and
depression symptoms in the 11th grade. It uses a random sample of student census data of
secondary education in Taiwan. The analyses combine LCA, SUR, and IPTW to identify
common PSE participation patterns, assess the predictors correlated with them, and then
estimate the causal effects of various PSE participation on school achievement and mental
health in high school.
This study extends our knowledge by demonstrating heterogeneous PSE participation
patterns that capture students’ workload and time spent on PSE after school. The present
study contributes to understanding the potential trade-off between school achievement and
mental health by identifying various long-term PSE participation patterns in junior high based
on students’ self-reported experiences. As would be expected from the previous literature,
PSE participation tends to increase students’ school achievement
[2,4,6,7,20–22]
. However,
previous work has overlooked the potential “side effect” of PSE on young people’s mental
health. More importantly, little research has offered insight into the patterns through which
Int. J. Environ. Res. Public Health 2021,18, 1222 14 of 18
PSE participation may trigger health-related consequences for young people. The use of
the person-centered approach in the current study extends our previous knowledge by
providing a better breakdown of which individual pathways may experience mental health
consequences, as a function of PSE participation and high school entrance examination.
The main result relates to the finding that always-takers and dropouts increase their
score on the entrance examination but at the cost of increasing their depressive symptoms in
the 11th grade. We did not find the same trade-off between school achievement and mental
health among early adopters, late adopters, or explorers. In line with our expectations
from the early literature [
11
–
13
,
30
], being always-takers over the three years may help
adolescents keep up with their peers in the entrance examination. However, they may also
have high risks of depression symptoms in the 11th grade while controlling for previous
school achievement and mental health. In contrast, a PSE late-adopters may gain nearly the
same positive effect on the entrance examination as always-takers, but with no apparent
mental health cost. These findings shed new light on the possible mental health risks of
PSE participants and students’ benefits to the high-stakes entrance examination.
For PSE participants, this study finds a significant correlation between two outcomes
among always-takers, dropouts, and explorers, which suggests the entrance examination
results may be consequential for students of these types of PSE participation in junior high.
Considering how popular PSE participation is in junior high in Taiwan, we expect that this
risk factor—in terms of the workload for always-takers and the burnout of dropouts—may
result in more severe impacts on adolescents’ later mental health. Further research is needed
to examine the effects of PSE intensity, duration, and quality on students’ psychological
and physical well-being.
There are some possible explanations as to why PSE always-takers and dropouts
suffer more in their later depression symptoms. First, being an always-taker of PSE
could indicate that students have difficulties in school achievement. Therefore, students
or parents may rely on PSE to help when children lag behind their school peers at the
beginning of junior high [
39
]. In the long run, the high intensity of PSE participation
may increase students’ workload, and result in long hours of studying after school and
increased stress in competing with peers. Second, PSE dropouts participated in PSE at the
beginning of the 7th grade but became less likely to attend PSE from the 7th to 8th grade.
By the end of the 8th grade, they no longer participated in PSE, which may indicate their
frustration or triumph in PSE participation in terms of academic competition. Based on
our findings depicted in the descriptive table, this group of students are more inclined
to withdraw from PSE because of frustration. Despite our efforts to capitalize on PSE
participation’s heterogeneous patterns, we do not have conclusive evidence or students’
interview data to back up our interpretations. Further research is needed to examine
students’ motivation or parent decision making in using PSE to support children’s success
in the school achievement.
Our findings suggest that late adopters also risk the trade-off between school achieve-
ment and depression symptoms if all students were randomly assigned to participate in
PSE. Our results extend previous work on PSE’s effect on adolescents’ school achieve-
ment and mental health by demonstrating different PSE participation patterns on the
improvement in entrance examination results but also highlight the trade-off students’
mental health.
It is worth noting that nearly 25% of junior high school students (N= 1888) did
not participate in any PSE activities. These students tend to have the lowest entrance
examination scores, lower family socioeconomic status, and lower depressive symptoms in
11th grade. The present study’s findings imply that certain low-income or students living
in non-intact families could improve their academic performance if they have chances to
gain access to extra learning resources, similar to those offered by PSE, without additional
financial burden. While PSE may serve as an extra learning opportunity for students,
our findings also show that PSE may not benefit everyone. It could also be a potential risk
factor for adolescents’ mental health. As more young people and parents would like their
Int. J. Environ. Res. Public Health 2021,18, 1222 15 of 18
children to go to a prestigious high school or university, it is not easy to ask them to give
up trying to use PSE as a means for such a goal. However, identifying the most vulnerable
students in terms of the effect of PSE participation on mental health is important, so that
students and their parents can develop a practical plan and make an effective decision
about the amount of time to participate in PSE per week, when to start PSE, or utilizing
stress-free supports to reduce the negative mental health effect of participating in PSE.
This study has several limitations. First, it relies on students’ self-reported measures,
such as high school entrance examination scores, 9th-grade academic ranking, or subject-
specific efficacy in junior high. Although the correlation between official scores and
self-reported school achievement was high, self-reported measures tend to be overstated
or understated and could bias our estimates in our attempted causal analysis. More re-
search is called for to use national standardized test scores as students’ outcomes after
PSE participation. Using national standardized test scores can minimize reporter bias
and reduce the risk of an inflated association between self-reported scores and school
achievement. Secondly, the measure of depression symptoms is not a typical instrument for
depression, for example, in contrast to the Center for Epidemiological Studies Depression
Scale (CES-D). This could present a challenge in the validity of this measurement as an
indicator of 11th graders’ mental health. Future research will need to consider a more
extensive and systematic measurement of mental health, which could further differentiate
PSE’s impacts on different dimensions of mental health. Thirdly, we do not have enough
information to identify in detail, the effect of a specific academic subject taken in cram
school. Our findings possibly mainly reflect the impact of cram schooling on English and
Math, the two most frequently taken subjects at cram schools by junior high students in
Taiwan [
5
]. Since we focus on the impact of various long-term PSE patterns on overall
academic achievement and mental health, our findings could be interpreted as the average
effects of these PSE patterns across cram-schooled subjects. Of course, it would be better if
later studies could show how long-term PSE involvement in a specific subject impacts this
subject’s academic achievement. However, how the PSE involvement of a particular subject
affects mental health would be a more challenging question to answer. Lastly, we do not
have specific measures of school achievement and depression symptoms (e.g., grade point
average, CES-D score) prior to the entrance examination or before high school enrollment.
Students’ early achievement could affect parents’ and students’ decisions in attending
different PSE patterns and their motivation to enroll in PSE. The inclusion of students’
earlier school achievement or depression symptoms may increase or maximize the strength
of our findings. Future research, with appropriate data, can look at the long-term trajec-
tory of outcomes or the time-lagged reciprocal effect between school achievement and
depression symptoms.
5. Conclusions
Given the strong emphasis on school achievement in Taiwanese society, this paper
provides an insight into whether there is a trade-off between mental health and school
achievement for secondary education students. We identify potential benefits in school
achievement and risks in mental health for adolescents who experienced various patterns of
PSE participation. This particular study finds that students who are PSE always-takers and
dropouts may experience some trade-offs between their senior-high entrance exam scores
and depression symptoms. The same trade-off did not happen for PSE early adopters,
late adopters, or explorers. In short, the effects of PSE are heterogeneous. PSE may offer
some students educational opportunities. It could also be a mental health risk to others.
Increasing PSE participation and depression symptoms in adolescence are becoming
global phenomena. Recognizing the negative impact of PSE participation on students’ mental
health calls for a thoughtful support system and intervention to prevent academic competency
and affects on adolescents’ later mental health and educational attainment
[11,27,28]
. The find-
ings of the current study provide insight into the arguments for early prevention, school-
and home-based intervention for the trade-off dilemma between school achievement and
Int. J. Environ. Res. Public Health 2021,18, 1222 16 of 18
mental health, and the need for large scale integration between prevention and educational
policies. We certainly do not think the findings of PSE’s effects in Taiwan could readily be
generalized to other societies. With the growing prevalence of shadow education outside of
East Asia, it is crucial to know more about how private supplementary schooling beyond
the school walls affects adolescents’ health worldwide.
Author Contributions:
Conceptualization, P.-Y.K. and I.-C.C.; investigation, I.-C.C. and P.-Y.K.;
data curation, I.-C.C., methodology I.-C.C. and P.-Y.K. Writing—original draft preparation, I.-C.C. and
P.-Y.K. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
Ethical review and approval were waived for this study
because the data is publicly available and contains no information that could be linked to respondents.
Informed Consent Statement:
According to the survey information offered by Taiwan Upper Sec-
ondary Education Database, informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
Restrictions apply to the availability of these data. Data was obtained
from Taiwan Upper Secondary Education Database (TUSED) and are available from https://use-
database.cher.ntnu.edu.tw/used/ with the permission of TUSED.
Acknowledgments:
The authors thank the CHER project and the data collection team at the National
Taiwan Normal University.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A. Latent Class Result of PSE Participation in the Junior High School
2-Class 3-Class 4-Class 5-Class 6-Class
AIC 30,918.81 28,395.42 26,724.14 26,306.59 26,093.00
BIC 31,006.61 28,530.51 26,906.51 26,536.24 26,369.93
BIC-adjusted 30,965.30 28,466.96 26,820.71 26,428.20 26,239.65
Entropy 0.934 0.966 0.965 0.974 0.967
AIC-DIFF 2523.38 1671.29 417.55 213.59
VUONG-LO-MENDELL-RUBIN
Likelihood −21,680.24 −15,446.40 −14,177.71 −13,335.07 −13,119.29
2 Times the LL Difference 12,467.67 2537.38 1685.29 431.55 227.59
p-value <0.001 <0.001 <0.001 <0.001 0.020
The decision to choose five latent classes as the best fitting solution among alternatives
is based on indices of entropy, AIC, BIC, and Vuong-Lo-Mendell-Rubin likelihood ratio
test [
33
,
34
]. Bold indicates the best solution of latent class model for identifying students’
patterns of PSE participation. AIC: Akaike information criterion; BIC: Bayesian information
criterion; DIFF indicated the AIC difference between models, such as calculating the AIC
differences between 2-Class and 3-Class.
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