To What Extent Do Key Stage Two Teachers Think That Mathematics Anxiety is Negatively Impacting Their Students’ Attainment in Mathematics?

Harry Mill

BA (Hons) Education Studies and Mathematics

Abstract

This article focuses on how Maths Anxiety [MA] negatively impacts attainment in Key Stage Two [KS2] children. This exploration covers a unique are of MA by seeking the persepctives of teachers’ working with younger students. The study looks to establish the presence of MA in KS2 classrooms, before analysing the breadth and cause of MA’s negative impact on attainment. Together, these factors help to establish the extent to which MA negatively impacts children’s attainment in mathematics. The research methods utilised were questionnaires and semi-structured, in person interviews. Findings suggest that whilst MA is not as prevalent in KS2 children as the literature suggests it is later in the educational timeline, where the impact on the attainment of those with MA is severe. This can be attributed to avoidance strategies students with MA display, with findings suggesting this inhibits teachers’ formative assessments of their students.

Introduction

Mathematics anxiety [MA] is defined by Bjälkebring (2019) as ‘a feeling of tension, worry, and fear in situations involving math-related activities’. Whilst this definition is not exclusive to mathematics lessons, they are the most common environment for ‘numbers, maths and mathematical calculations.’ Mathematics is becoming an increasingly important part of people’s lives, with the Government recently introducing a new proposal to teach mathematics in some form to everyone until the age of eighteen (Sunak, 2023). Therefore, those suffering with MA are going to be exposed to even more troubling experiences in the future. This makes MA an important area to conduct further research. To deal with a problem such as MA, it seems important to look at how it impacts younger children, so strategies can be implemented to help support children at an earlier age who may be struggling with these experiences. There is a breadth of research relating to how MA impacts older students with a lack of research relating to MA in younger children (Dowker et al., 2012; Hill et al., 2016). This incidental finding was one which suggested a need for further research which prompted this project. Therefore, this article has explored teacher perspectives regarding MA and how this can negatively impact attainment.

The purpose of this study is to explore whether teachers in Key Stage Two [KS2] believe that their students are affected by MA, and in what ways they are impacted. The majority of current literature focuses on the impact MA has on people in their later years of education and life itself (Lee & Johnston-Wilder, 2010; Marshall et al, 2017). When MA is explored in younger children, it is often assessed through tests and surveys with children themselves (Krinzinger et al., 2009; Thomas & Dowker, 2000). However, the Teachers’ Standards (2011) requires teachers to ‘be accountable for pupils’ attainment, progress, and outcomes’ (p.10). Hence, it is important to explore primary teachers’ perspectives on the extent of the impact of an issue that the literature suggests has a negative impact on students’ attainment (Lee & Johnston-Wilder; Punaro & Reeve, 2012). Using online questionnaires and semi-structured interviews, this research takes the form of a mixed methods case study to gain a deeper insight into MA from teachers within one specific setting. The study originated from a ten-day volunteering experience in a mainstream primary school in KS2 classrooms. This research is small-scale and whilst this means that it cannot claim to contain proof of the impact of MA on KS2 children, it can be used to identify possible areas for further research by comparing it to the current literature.

Literature Review

The detrimental impact of MA is consistently seen throughout the available literature (Ashcraft, 2002; Devine et al., 2012; Hembree, 1990). However, there is a distinct discourse over the breadth of impact MA has on the population. Lee and Johnston-Wilder (2010) developed a construct of mathematical resilience to combat the wide-ranging impact that they believe MA has on schools. Their work demonstrates the view that MA has a wide-reaching impact on large amounts of students. This is supported by Ashcraft and Moore (2009) whose research in the US found that MA impacts ‘a considerable proportion of the population.’ Several pieces of research quote the figure that 17% of the US population have high MA (Luttenberger et al., 2018; Paechter et al., 2017). Ashcraft and Moore (2009) developed this figure using a statistical definition based on standard deviation from the normal curve. However, they were clear that this figure was only useful for forming research groups and that it would be a mistake to draw the conclusion that 17% of the population suffered from MA (Ashcraft & Moore, 2009). Research by the Organisation for Economic Cooperation and Development [OECD] (2012), published in a Programme for International Student Assessment [PISA] report, found that in a study 31% of 15-year-olds stated that they get very nervous completing mathematics problems. The difference between this figure and Ashcraft and Moore’s (2009) 17% may be down to the age range of the study. Whilst Ashcraft and Moore (2009) were developing a figure for the entire population, PISA’s study focussed on 15-year-olds, meaning all participants would most likely be taking mathematics exams within the next two years. This gives them greater cause to be anxious about mathematics, as opposed to members of the US population who will likely have very few encounters with mathematics. This may explain the difference in figures between the two studies. The lack of clarity around figures readily quoted serves to highlight the uncertainty that is still present in research about the prevalence of MA, and this makes it even harder to establish its impact on attainment.

The literature suggests that MA’s impact on attainment is more severe than other subject-specific anxieties (Dowker et al., 2016; Punaro & Reeve, 2012). What is unclear however, is which students are impacted most by MA. Research highlights the negative correlation between MA and performance in mathematical tasks (Ashcraft & Moore, 2009; Devine et al., 2012), although Dowker et al. (2016) are unsure whether poor mathematical ability leads to MA, or if MA leads to poor mathematical ability. It is believed to be something of a vicious cycle, where poor performance increases anxiety which has a detrimental impact on further performances (Carey et al., 2016; Dowker et al., 2016). Research by Hembree (1990) found that people with high MA who had undergone Cognitive Behavioural Therapy [CBT] subsequently reported mathematical scores within the normal range. Assuming the CBT did not contain any mathematical teaching, it follows that anxiety was a factor in the lower attainment scores in mathematics (Ashcraft & Moore, 2009). This suggests that if MA can be lowered then there will be a lesser impact on attainment in mathematics.

As well as ascertaining the demographic that MA impacts, it is important to consider the ways in which MA manifests itself and the impact this has on attainment. Ashcraft (2002) theorised that MA has a negative correlation with mathematical attainment due to avoidance strategies employed by those high in MA. This was believed to lead to a lack of practice for students high in MA compared to other, less mathematics anxious students (Ashcraft, 2002). This view is supported by Lyons and Beilock (2011), who believed that those negatively impacted by MA were highly avoidant of mathematics-related tasks. Furthermore, research has found that alongside the avoidance strategies that students with MA implement, MA also compromises the function of working memory (Cassady & Johnson, 2002; Eysenck et al., 2007; Macher et al., 2012). This suggests that it is not only a lack of practice that impacts the attainment of students with MA, but that high maths-anxious individuals are already using some of their limited working memory resources worrying about their anxiety whenever they perform a maths task (Ashcraft & Moore, 2009). The Teachers’ Standards (2011) states that it is a teacher’s responsibility to ‘have a secure understanding of how a range of factors can inhibit pupils’ ability to learn, and how best to overcome these’ (p.11). As MA is believed to inhibit attainment, teachers should have a good knowledge on how it impacts students, making the piece suitable for identifying the ways MA manifests itself and impacts attainment.

Certain literature, however, highlights a different response that MA can invoke in students. A study by Paechter et al. (2017) showed a positive relationship between MA and performance in psychology undergraduates during a statistics examination. Paechter et al. (2017) described this as a surprise result, and theorised that it was possible that MA had led to an increased motivation to avoid failure and hence resulted in greater preparation. This idea can also be seen through the research of Lyons and Beilock (2011) and Wigfield and Meece (1988), who believe that some highly mathematics-anxious individuals invest more effort and recruit more cognitive resources in mathematical problem solving. The context of this however was in trying to explore why not all students high in MA perform poorly, and there was an acknowledgement of the generally negative impact of MA on attainment (Lyons & Beilock, 2011; Wigfield & Meece, 1988). A study by Wang et al. (2015) exploring the relationship between MA, maths motivation and maths cognition suggested that higher mathematics motivation in students with moderate MA can lead to higher attainment in mathematics, however the general impact of MA on attainment is generally debilitative.

Most research on MA is focussed on secondary age children or undergraduate students, with relatively little research focussing on primary age children (Dowker et al., 2012; Hill et al., 2016). Research that does focus on MA in primary school children shows interesting results. Hill et al. (2016) found that whilst there was a reliable negative correlation between MA and secondary students’ arithmetic performance, there was no such relationship in primary students. This led to the conclusion that MA’s negative impact on attainment was developed later in the educational timeline (Hill et al., 2016). Thomas and Dowker (2000) and Krinzinger et al. (2009) also found that the mathematical performance of children between six and eight years old was related to liking mathematics but not to anxiety. This suggests that MA is not an issue that affects the attainment of KS2 children, despite most literature suggesting that MA was present in children of this age (Gierl & Bisanz, 1995; Hill et al. 2016). There is some literature, however, that suggests that MA does not emerge until preadolescence, which is commonly defined as 9-12 years old (Punaro & Reeve, 2012). This would suggest that MA would only be seen during the later stages of KS2. A similar idea to this is promoted by Devine et al. (2012), whose research suggested that mathematics anxiety develops in children at some point during primary school age.

It is important to note that most of the research available on MA in primary schools was conducted by the comparison of the results of a MA questionnaire and the results of mathematical tests (Hill et al. 2016; Krinzinger et al., 2009; Thomas & Dowker, 2000). This may not be the most effective method of ascertaining the impact of MA in primary school children, as Punaro and Reeve (2012) state that ‘even though academic anxieties may exist in preadolescent children, it is unclear whether children would be able to accurately describe these experiences because of immature metacognitive abilities’ (p.1). However, this research seeks to focus on the perspective of teachers on the effect MA has on their students’ attainment, an area which is not covered in the current literature. By combining this factor with the relatively little focus on primary school children, this research covers a unique aspect of the impact of MA. Therefore, based on the research findings discussed it can be seen that there is a need to explore teachers’ perspectives on the impact of MA on their student’s attainment in mathematics.

Methodology

A mixed methods case study was implemented to answer the research question. This featured a Jisc online questionnaire, followed by in person interviews. Using two methodological approaches ensured that the research was approached from different angles and hence could be triangulated to increase reliability and validity (Brett-Davies, 2007). The study was conducted under an interpretivist research paradigm, focussing on qualitative data in both the interviews and questionnaire, supplemented by a smaller number of quantitative questions on the questionnaire (Denscombe, 2021). By using a mixed method approach, a more comprehensive understanding of the teachers’ perspectives was achieved, whilst minimising the weaknesses of both qualitative and quantitative data at the same time (Bell & Waters, 2018; Cohen et al., 2018). Furthermore, most of the research available in the literature review was conducted using quantitative data, meaning a mixed methods approach provides this research with a unique insight into MA. All interviews and questionnaires took place with KS2 teachers from an urban primary school in the Lincolnshire area. As the research required the perspectives of KS2 teachers, a purposive sample ensured that the sample met the needs of the research question (Cohen et al., 2018; Nutbrown & Clough, 2012). The sample also showed elements of convenience sampling, with participants all coming from one school (Cohen et al., 2018). This meant that the research was conducted in the form of a case study. Implementing a case study approach allowed the research to be done in depth (Denscombe, 2021), enabling a more holistic view of the impact of MA on attainment. A case study does limit the generalisability of the findings (Ashley 2012; Elliott & Lukes, 2008), as generalisability would require a much larger research breadth and focus (Nutbrown & their participation (Cohen et al. 2018). The interviews were conducted with five initial questions, all of which were open questions. Using open questions allowed the participants to express their perspectives and lead the conversation (Bell & Waters, 2018). This highlights the mainly interpretivist nature of the research, using interviews to interpret teachers’ perspectives (Denscombe, 2021). Developing lines of enquiry were also explored in the interviews through unique follow up questions to ensure that all points that participants made were detailed and explained, which is an advantage of using semi-structured interviews (Denscombe, 2021). Despite being in person, meetings were recorded on Microsoft Teams, allowing for usage of Microsoft Teams’ transcription software. Transcriptions were then transferred to an encrypted hard drive and the recordings deleted to protect the data of participants. Any minor errors in the Teams transcription were identified and altered by the researcher. Once all the data were collected, thematic analysis on the information collected took place. The transcripts were reviewed to find common perspectives and themes, using inductive coding to find relevant data in relation to the question. Using inductive coding allowed the research to be led by the data, as opposed to having preconceptions of what the themes should be and hence trying to fit them into the data (Cohen et al., 2018).

Consent for the interviews was gained though the participant consent forms drawn from the Bishop Grosseteste [BGU] Ethics Policy (2019) and aligning with BERA (2018) Ethical Guidelines for educational research. The participant information sheets were placed at the beginning of the Jisc online questionnaire, so that participants understood what they were taking part in. This was followed by a consent form, ensuring all participants consented to the collection and analysis of their data as part of the academic research, before they started the questionnaire. When conducting the in-person interviews, a copy of the participant information sheet was given to the teachers and a consent form that had to be completed and returned before the interview to confirm that consent has been given. Each participant was made aware of their right to withdraw throughout the process and given the information of how to do so. Participants were also provided with details of who to contact if they had any questions.

Presentation and analysis of findings

This section will present the findings of the four completed questionnaires and three semi-structured interviews, using the data that has been inductively coded to analyse what the findings show and how they compare to the previous research found in the literature review. Participants will be referred to as Teacher A, Teacher B, Teacher C and Teacher D to maintain anonymity, with Teachers A, B and C being the three teachers who completed interviews. The findings were split into analysing what the participants understood by the term MA, establishing the presence of MA in classrooms, analysing how it negatively impacts attainment, and finally the breadth of impact of MA on attainment in classes.

Teachers’ understanding of MA.

Prior to discussing the impact that teachers feel MA has on their students, it is important to note what teachers understand by the term MA. This is because if a participant has a different understanding of MA to the literature, then their perspective on how it negatively impacts attainment in maths may be different. All four participants in the questionnaire responded yes to the question ‘Have you heard of the term maths anxiety?’. This may indicate that the participants have to deal with MA in their classrooms, however the question’s primary purpose was to help establish if the participants had an understanding and awareness of MA in education.

Building on this, the questionnaire asked participants what they understood by the term MA, with the responses presented in Table One. MA is described by Bjälkebring (2019) as ‘a feeling of tension, worry, and fear in situations involving math-related activities’ (p.1). The responses of Teachers A and C are both very similar to this, using the respective key terms of fear and worry. Teacher D’s response mentions an ‘escalated emotional state’ which eludes to Bjälkebring’s (2019, p.1) definition. This suggests that these teachers’ understanding of MA is in line with the available literature’s definition. However, the response of Teacher B differed slightly, as they believe that MA is when children struggle with maths because they do not believe they can do it. This does not match the definition of MA, instead demonstrating a possible effect of MA, rather than its cause. This should not cause a major issue however, as the response still demonstrates sufficient understanding of how MA affects children to ensure their data are useful.

The presence of MA in primary schools.

All the teachers’ surveys saw examples of MA within their mathematics classes. This can be seen in Table Two, which shows the responses to the question ‘What examples of MA do you see during your mathematics classes?’ The response of Teacher 3 best highlights an example of MA, with their response stating that children were ‘worrying that the work is too tricky’ corrolating with the idea of MA as described by Bjälkebring (2019, p.1). Furthermore, half of the respondents were able to identify multiple examples of how MA is present during their classes. This suggests that MA may not be a rare occurrence within their classrooms. The ability of the participants to come up with examples of MA in their classes supports the views of Hill et al. (2016) and Gierl and Bisanz (1995) that MA is present in primary school age children. However, the demographic of the participants does contradict the findings of certain literature. Punaro and Reeve’s (2012) findings that MA emerges during preadolescence (between 9-12 years), are contradicted by the experiences of the participants, 50% of whom teach in Year 3, an age at which Punaro and Reeve (2012) believe teachers should not see examples of MA in their classes.

One surprising result from the questionnaire was that there was a split between teachers’ perspective on the severity of MA compared to anxiety seen in other subjects. Question eight ‘Have you noticed more anxiety from your children during their mathematics lessons than in other subjects?’ received a response of yes from 50% of participants and no from the other 50%. This compares interestingly with the participants’ response when asked to give examples of MA they see in their classes. Even though all four participants could give examples of MA, and all three interviews revealed several examples of MA in students, 50% of those surveyed do not feel like they notice more anxiety in mathematics classes than in other subjects.

These findings suggest that teachers are also seeing comparable levels of anxiety in other subjects. This contradicts the literature which found that MA had a more severe impact on attainment than other subject-specific anxieties (Dowker et al., 2016; Punaro & Reeve, 2012). For MA to have a greater impact on attainment than other subject-specific anxieties, it is reasonable to expect that more anxiety would be seen during mathematics lessons than other subjects. As this was not the case for 50% of participants, it follows that these teachers also see high levels of anxiety from their students in other subjects. Further research shows that there are other subject-specific anxieties, such as literacy anxiety, although research into these is relatively sparse (Hill et al., 2016; Punaro & Reeve, 2012). Research by Di Lonardo Burr and LeFevre (2021) found that literacy anxiety was present in undergraduates, albeit at a lower rate than MA. However, there is a lack of research into the impact of other subject-specific anxieties in a primary setting, an area which given these findings could be extremely important in preventing anxieties such as literacy anxiety becoming just as prominent as MA.

How MA negatively impacts attainment.

This research study found that MA’s negative impact on attainment may be caused by the avoidance strategies that students with high MA exhibit, due to how this inhibits teachers’ ability to check their understanding. All three interviewees mentioned that children’s MA manifested itself through avoidance strategies, with Teacher B and Teacher C describing children with MA as being deliberately slow to start their work. Teacher A gave an example of children deliberately covering up their work so that the teacher could not check if they had answered correctly whilst walking around the class. This suggests that avoidance strategies are negatively impacting on attainment due to the difficulty it causes for teachers when they are trying to formatively assess understanding of their students.

This provides a different view to Ashcraft’s (2002) perspective that students who often display avoidance strategies and also present as having high MA may demonstrate negative attainment in Maths due to the lack of practice these students are getting compared to others. The results of the interviews did however, support Lyons and Beilock’s (2011) view that those high in MA were highly avoidant of maths. One teacher stated that ‘children with MA do almost anything they can to not engage with mathematics’, an almost identical viewpoint to Lyons and Beilock’s. This lack of engagement in mathematics may then lead to poor performance in the subject, causing an increase in MA which leads to more avoidance, and the start of a detrimental cycle, as stated in the literature review (Carey et al., 2016; Dowker et al, 2016). It is possible that both of these factors, the lack of practice avoidance strategies lead to, and the difficulty for the teacher to formatively assess a child’s understanding of the topic, cause the negative correlation seen in the literature between MA and mathematical attainment (Ashcraft & Moore, 2009; Devine et al., 2012).

At this point it is important to note that this research is being conducted three years after the outbreak of the Covid-19 pandemic, whereas all previous research cited in the article was conducted prior to this event. This may impact the findings as Covid-19 caused significant gaps in primary school children’s foundational maths knowledge, due to a lack of consistency in their early education. This is highlighted in a report by the Royal Society (2022) which found that teachers believed that over 50% of their students between three and nineteen-years-old were more than three months behind in mathematics because of Covid-19. It is possible then that some of the MA that participants discussed was influenced by their children falling behind because of the pandemic, supporting the idea that it is poor mathematical performance that leads to MA and not vice versa. However, it is possible that the vast increase in those falling behind in mathematics caused an increase in MA, beginning the downward spiral described by Carey et al. (2016) and Dowker et al. (2016). Future comparative studies on MA and mathematical attainment pre-Covid and post-Covid may be useful in helping to establish the relationship between the two factors, which could eventually aid the decrease in MA in children.

This research study failed to identify any perceptions of positive impact of MA on KS2 children’s attainment. The questionnaire established that 75% (n=4) of participants believed that MA negatively impacted the attainment of children in their class in mathematics. The one participant who responded no to this question later disclosed that they answered this on the belief that MA had no negative impact on the class as a whole, meaning that 100% of participants believed those with MA were negatively impacted. This misconception regarding a question on the questionnaire is a slight weakness of the study, however the fact 75% of those surveyed were then interviewed allowed any misconceptions to be caught and rectified. All three interviews also failed to result in any mention of a positive impact of MA on students.

This contrasts strongly with some of the literature, such as Paechter et al.’s (2017) surprise finding of a positive correlation between MA and results on a statistics test. The results of this research serve to further highlight the unusual nature of the result found by Paechter et al. (2017). The results of this research study also contradict the perspective put forward in the literature review was that some high MA students increased their effort in maths and hence their attainment was not negatively impacted by MA (Lyons & Beilock, 2011; Wigfield & Meece, 1988). No examples of this were found through interviews, with all participants repeatedly pointing out the negative impact that MA has on their students’ attainment. However, this idea was formed to explain why a small percentage of students with MA saw a positive impact on their attainment. Therefore, it is possible that this is an impact of MA that is sometimes seen, but that there were no children within the participants’ classes that demonstrated this response to MA. Further research with a larger range of schools and ages would help to gain an improved perspective on this idea. There was also no evidence in the interviews of higher mathematical motivation in any students with moderate MA, contrasting some of the ideas of Wang et al. (2015). However, Wang et al. (2015) acknowledged the generally debilitative impact that MA has, whilst also expressing the belief that it is only those with moderate MA who can use greater motivation to achieve higher attainment. This means that the results of this research cannot disprove the findings of Wang et al. (2015).

Breadth of impact of MA on attainment

Participants believed that MA affected between two and four of their students, with percentages ranging between 9-19% of classes, as shown in Table Three. Whilst teachers are not medical or psychological professionals and therefore do not have the expertise to officially diagnose MA in children, the Teachers’ Standards (2011) requires that teachers ‘have a secure understanding of how a range of factors can inhibit pupils’ ability to learn, and how to overcome these’ (p.11). MA clearly inhibits pupils’ ability to learn (Ashcraft, 2002; Devine et al., 2012; Hembree, 1990), meaning that it is required that teachers are aware of who in their classes may be inhibited by MA. This means that participants should be able to give a relatively accurate idea of how many of their students have MA. Percentages found in Table Three were calculated by dividing the number of students teachers believed had MA by the total numbers of pupils in their class, before multiplying by 100 to give a percentage. One teacher could not be sure and hence gave a range of 2-3, which was carried through to give two percentages.

Even the highest percentage found through the questionnaire (19%) is significantly lower than the OECD (2012) study that found 31% of 15-year-olds were very nervous whilst completing mathematics problems. The results are much closer in value to the statistical figure based off the normal curve that Ashcraft and Moore (2009) placed at 17%. This may suggest that the reason for the higher figure found in the OECD study was in fact down to stress caused by upcoming exams, as hypothesised in the literature review. Further research suggested that test anxiety was closely related to the MA of students, and that reducing test anxiety could help to alleviate MA (Hembree 1990; Xie et al., 2018). To explore this result further, methods shown to be successful in studies to reduce test anxiety could be trialled to test their impact on MA. One example of this could be Erbe’s (2007) introduction of a cheat sheet prepared by students, which was found to reduce test anxiety. If these methods are successful then this could lead to a drastic reduction in the negative impact MA has on attainment across all ages, including KS2.

Conclusion and Implications

This study’s findings suggest that MA is present in primary schools, supporting most literature on the topic (Gierl & Bisanz, 1995; Hill et al., 2016). However, the findings also suggest that other subject specific anxieties were more prevalent than the current literature believed to be the case (Dowker et al., 2016; Punaro & Reeve, 2012). Further research into other subject specific anxieties, such as literacy anxiety, could be highly valuable in developing an understanding of, and limiting, their presence in children. There were no positive aspects of MA identified by the study, which contradicts but does not disprove the findings of Lyons and Beilock (2011), Wigfield and Meece (1988) and Wang et al. (2015) that show some increased motivation for a small number of students with high MA. Instead, participants believed that the impact of MA on attainment was extremely negative. This was because of the detrimental impact of the avoidance strategies employed by children with MA. Whilst the literature felt that it was the lack of practice children with MA were getting due to these avoidance strategies that was the problem, the teachers believed that it was instead down to the difficulties when formatively assessing the understanding of children with MA due to their avoidance of the work. The impact of the Covid-19 pandemic provides a unique opportunity for further research to analyse the impact that a large number of children falling behind in their work had on MA.

Whilst the small-scale nature of this piece must be noted, involving only four participants, the choice of teachers as the participants made it valuable. Teachers are required to understand how factors such as MA affect attainment (Department for Education, 2011). This means that they should show secure knowledge on the issue of MA and how it impacts their students’ attainment. However, any further research into teachers’ perspectives on MA should seek to use a greater number of participants from different settings, to help improve the generalisability of the findings (Cohen et al., 2018). The research report also found that participants did not feel that MA was affecting as many of their students as the literature suggested it should. This may have been down to the sample of children, with other studies such as the OECD’s (2012) study looking at 15-year-olds. Due to the disparity in the findings compared to the OECD (2012) study, further research into the impact that test anxiety in 15-year-olds may have on MA could help establish whether test anxiety is causing more children to have MA. The results of this further research could help to direct the efforts to reduce MA in children at all ages.

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