# 30. Children after starting school Section 20 covered the first year of a child’s life. Section 18 discussed how much money and time raising a child requires. The period from ages 3 to 18 was previously left blank in this book; this section fills that gap. The advice on screen time by age group starts at age 0, because official classifications are 0–3 years, 3–6 years, and elementary/middle school — grouping them differently would make the guidance harder to use. This section answers one core question: when “don’t delay learning” conflicts with “protect physical health,” which actions absolutely cannot wait? They cannot wait because each has a strict time window; missing it means permanent consequences. Whether academic pressure should be so intense is not discussed here — only the relevant time windows and figures are provided. The first eight items and the final two address death and lasting physical harm. Item 9 (avoiding products that claim to “cure myopia”) deals with costs. Items 10 (official rules on sleep, homework, and sports rankings) and 11 (keeping school enrollment after a leave of absence) concern time commitments. Information on drowning, traffic safety, helmets, and HPV vaccination can be found in Section 1. Guidance for infants and toddlers is in Section 20. Issues involving online scams and in‑app purchases are covered in Section 5, while red lines minors must not cross are detailed in Section 9. Recognizing emergencies and calling for help are explained in Section 13, and what happens to children after a parent’s death is addressed in Section 29 — none of these topics are repeated here. ### 1. Child reports sudden, worsening pain — rush to the hospital right away; don’t let him wait until after school - Cost: No cost at all. Just take a half‑day off work and take your child to the emergency department. - In plain terms: Some medical conditions are time‑critical — the outcome depends on how many hours pass from symptom onset. When a boy suddenly feels severe pain on one side of the scrotum, it may be testicular torsion: the blood vessels feeding the testicle become twisted, cutting off its blood supply. If treated within 6 hours, there’s a 97.2% chance of saving the testicle; after 19–24 hours that chance drops to only 42.5%. This kind of pain won’t wait until after school or until the end of an exam. - Benefit: Researchers compiled data from 30 case series and 2,116 patients with testicular torsion. For 1,283 of those cases the outcome was tracked in 6‑hour intervals. From the start of pain: 97.2% of testicles were saved at 0–6 hours, 79.3% at 7–12 hours, 61.3% at 13–18 hours, 42.5% at 19–24 hours, 24.4% at 25–48 hours, and just 7.4% after 48 hours. Looking at broader windows, 90.4% of testicles remain intact if treatment occurs within 12 hours; 54.0% are still salvageable at 13–24 hours, and 18.1% after 24 hours. The authors conclude that the window for preserving a testicle can be longer than the commonly cited 6–8 hours. Therefore, even if pain has been present for a while, prompt medical care is still essential — don’t assume it’s “too late” to get help. - Evidence grade: A - Sources:Mellick LB, et al. (2019). A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatric Emergency Care. - Notes: Tell your son in advance: if he suddenly feels severe pain, he should speak up right away — no need to feel embarrassed. Testicular torsion is most common in adolescent boys; many hesitate to ask for help because they’re shy. Other conditions that also worsen hour by hour include acute appendicitis (which can perforate if delayed), diabetic ketoacidosis, and meningitis. For these, the exact time‑based impact on outcomes isn’t detailed in this section. Their common warning sign is sudden onset and steadily worsening pain unlike anything experienced before. How to recognize emergencies and call for transport are covered in Section 13. ### 2. Don’t delay necessary treatment just to “wait until exams are over”; certain treatment windows depend on bone growth, not exam schedules - Cost: No monetary cost involved. This point concerns whether to start treatment early or late, not expense. Taking time off school and returning for follow‑ups do cost time, while the actual cost of treatment is separate. The real challenge is that braces must be worn at least 18 hours a day, which can be uncomfortable for kids. - In plain terms: Scoliosis is a sideways curvature of the spine. A brace is a rigid shell worn on the back that helps keep the spine straight. When worn while bones are still growing, it greatly reduces the chance of needing surgery: 75% of patients wearing braces succeed, compared to only 42% who simply receive observation. This treatment window is tied to the timing of bone maturation, not to middle‑school or college entrance exams. Waiting until after exams often leaves surgery as the only option. - Benefit: A multi‑center trial enrolled 242 adolescents with idiopathic scoliosis who met brace‑wearing criteria. Of these, 116 were randomly assigned to wear braces while 126 chose on their own whether to wear them. Success was defined as the curve remaining below 50 degrees by the end of growth; failure meant exceeding that threshold. Among those assigned to braces, 75% succeeded versus 42% in the observation group (OR 4.11, 95% CI 1.85–9.16). Combining both groups gave success rates of 72% vs. 48% (OR 1.93, 95% CI 1.08–3.46), meaning braces increase the odds of success by roughly 1.9 times. Success rates rose with longer daily wear time (P<0.001), a relationship unlikely to be coincidental. The trial was stopped early because braces proved effective. - Evidence grade: A - Sources:Weinstein SL, et al. (2013). Effects of bracing in adolescents with idiopathic scoliosis. New England Journal of Medicine. - Notes: Scoliosis serves as a good example here because it has randomized trials, a clear treatment window, and is a common focus of student health screenings (see Section 7). Similar situations include strabismus, amblyopia, dental caries, and certain elective surgeries for congenital heart defects. In all these cases, later treatment yields poorer outcomes or higher costs. Discuss the exact timing with a specialist. Missing school is not a major issue: during compulsory education students may take up to one year of leave while retaining their enrollment status (see Section 11). ### 3. When a child is bullied, report it to school the same day and request a written response; for physical assault, theft, or rumor spreading, call the police immediately - Cost: There is no cost involved. Speak to the homeroom teacher and the school’s anti-bullying committee. To call the police, dial 110. The hard part is resisting pressure to “keep things quiet” or avoid making a big deal out of it. - In plain terms: Children who experience peer bullying are roughly 2.2 times more likely to have suicidal thoughts than those who are not bullied, and about 2.6 times more likely to attempt suicide. Schools must investigate any bullying report right away; if bullying is confirmed, disciplinary action must be taken against the offending students. In cases where bullying violates public order laws or may constitute a crime, schools cannot conceal the facts and must inform police. Therefore, reporting the incident the same day and demanding a formal written response is crucial — simply asking the teacher to “talk to him” is not enough. - Benefit: This conclusion is based on 34 studies involving 284,375 children and teens. Peer bullying is linked to suicidal thoughts, with an OR of 2.23 (95% CI 2.10–2.37); in other words, the likelihood of such thoughts is roughly 2.2 times higher than among non-bullied youth. Nine additional studies with 70,102 participants show bullying correlates with suicide attempts, with an OR of 2.55 (1.95–3.34); this translates to about 2.6 times higher risk. These results hold true regardless of gender, age, or study quality. Cyberbullying carries an even stronger link to suicidal thoughts than physical bullying. Article 21 of the “Regulations on Protecting Minors in Schools” lists five types of bullying: physical violence (punching, kicking, slapping, biting, pushing, or pulling); verbal abuse, mockery, or derogatory nicknames; theft, vandalism, or deliberate destruction of property; deliberate exclusion or isolation; and online defamation or spreading false rumors. The article also states that if a stronger or older student intentionally commits such acts, causing physical harm, property damage, or emotional distress, it qualifies as bullying. Article 22 requires teachers to pay attention to any signs of emotional distress or physical injury and report them promptly. Article 23 mandates that schools investigate all reports, have the anti-bullying committee determine whether bullying occurred, and involve parents in the process. If bullying is confirmed, educational or disciplinary measures must be taken. Serious cases violating public order laws or criminal statutes must be reported to police and education authorities without delay (effective nationwide since September 1, 2021). - Evidence grade: A - Sources:van Geel M, et al. (2014). Relationship between peer victimization, cyberbullying, and suicide in children and adolescents: a meta-analysis. JAMA Pediatrics. ；教育部 (2021). 未成年人学校保护规定（教育部令第 50 号，第二十一、二十二、二十三条）. - Notes: If a child shows unexplained injuries, suddenly refuses to go to school, or repeatedly loses personal items, these signs should be taken seriously per Article 22. This analysis combines data from multiple studies and relies on observational records rather than controlled trials; thus it cannot definitively prove bullying alone causes suicide, but it clearly shows a significant increase in risk. Additionally, the “Comprehensive Plan for Addressing Bullying Among Primary and Secondary Students” stresses the need to distinguish bullying from ordinary horseplay among kids. In short, schools have a legal duty to conduct proper investigations and cannot dismiss incidents as mere “kids just playing around.” ### 4. Ensuring that children spend at least 2 hours outdoors each day is currently the only myopia‑prevention method backed by randomized trials - Cost: There is no monetary cost. However, it requires setting aside time each day — often at the expense of homework or online classes. The real challenge is maintaining this routine daily, not just occasionally. - In plain terms: A randomized trial was conducted at 12 primary schools in Guangzhou: first‑grade students were given an extra 40 minutes of outdoor activity per school day. After three years, the myopia rate in these schools was 30.4 %, compared with 39.5 % in schools without the added classes — a reduction of 9.1 percentage points. The Health Commission recommends at least 2 hours of daytime outdoor time per day, or a total of 14 hours per week. Cloudy days and standing outside during recess also count. - Benefit: In this trial, first‑grade students from 12 Guangzhou schools were randomly assigned to intervention or control groups (952 students in the intervention group, 951 in the control group; mean age 6.6 years). The intervention involved adding a 40‑minute outdoor class each day and encouraging parents to take their children outdoors after school. Over three years, the new myopia rate was 30.4 % in the intervention group (259 of 853 eligible participants) versus 39.5 % in the control group (287 of 726 eligible participants). The difference was –9.1 percentage points (95 % CI –14.1 to –4.1, P<0.001), indicating a true reduction ranging from roughly 4 to 14 percentage points. The average increase in refractive error was –1.42 D in the intervention group versus –1.59 D in the control group, a difference of 0.17 D (P=0.04); the intervention thus slowed progression slightly. D is the unit used to measure refractive error. No significant difference was observed in axial eye length between groups (P=0.07). The “Ten Core Principles for Myopia Prevention” also call for at least 2 hours of daytime outdoor activity per day or 14 hours per week; they note that even on cloudy days this activity provides protection and advise avoiding peak midday sun. - Evidence grade: A - Sources:He M, et al. (2015). Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA. ；国家卫生健康委办公厅 (2023). 防控儿童青少年近视核心知识十条（国卫办妇幼函〔2023〕278 号）. - Notes: The trial lasted only three years and involved children starting at age 6. A 9.1‑percentage‑point difference means it can help prevent myopia in some children, but it does not guarantee protection for everyone. The same guidelines also recommend maintaining a distance of “one foot, one fist, one inch” while reading or writing, taking a 20‑second break to look into the distance after 20 minutes of close‑up work, limiting non‑educational screen time to 15 minutes at a time (no more than one hour per day), and recognizing that simply standing outside during recess counts toward the daily outdoor requirement — it is not the same as attending a formal PE class. ### 5. No screen time for children aged 0–3; limit it as much as possible for ages 3–6; for school‑age kids, non‑educational screen use should not exceed one hour per day - Cost: There is no monetary cost. The real challenge is keeping screens out of children’s hands and encouraging parents to cut down on their own screen time in front of them. - In plain terms: The Health Commission has set strict guidelines: no screens for children aged 0–3, and they should be kept away from screens as much as possible for ages 3–6. For school‑age students, non‑educational screen use must be limited to no more than 15 minutes at a time and no more than one hour per day. The reasoning is that prolonged close‑up screen exposure depletes a child’s “far‑sightedness reserve,” leading to earlier onset of myopia. Research linking screen time directly to myopia isn’t as conclusive; the strongest evidence comes from studies showing that two hours of outdoor activity per day helps prevent myopia. - Benefit: Article 4 of the “Ten Core Principles for Preventing Myopia in Children and Adolescents” states: “Children aged 0–3 should not use smartphones, tablets, computers, or other screen‑based electronic devices; children aged 3–6 should avoid such devices as much as possible; for school‑age students, non‑educational screen use should be limited to no more than 15 minutes at a time and no more than one hour per day.” It also notes that “prolonged close‑up use of screen devices can deplete a child’s far‑sightedness reserve, a key factor in the early and frequent occurrence of myopia.” In 2018, eight government agencies, including the Ministry of Education, issued similar recommendations, adding that “the younger the child, the shorter the recommended continuous screen time.” Scientific research is far less definitive: a systematic review examined 33 studies involving participants from 3 months to 33 years of age; only 11 contributed to the pooled analysis. When only smartphones and tablets were considered, the odds ratio for myopia was 1.26 (95 % CI 1.00–1.60, I² = 77 %). Including computers raised that figure to 1.77 (1.28–2.45, I² = 87 %). The authors concluded only that there may be a link, noting that none of the 33 studies measured screen time reliably. - Evidence grade: B - Sources:国家卫生健康委办公厅 (2023). 防控儿童青少年近视核心知识十条（国卫办妇幼函〔2023〕278 号）. ; 教育部等八部门 (2018). 综合防控儿童青少年近视实施方案（教体艺〔2018〕3 号）. ; Foreman J, Salim AT, Praveen A, et al. (2021). Association between digital smart device use and myopia: a systematic review and meta-analysis. The Lancet Digital Health, 3(12), e806-e818. ; Madigan S, McArthur BA, Anhorn C, Eirich R, Christakis DA (2020). Associations between screen use and child language skills: a systematic review and meta-analysis. JAMA Pediatrics, 174(7), 665-675. - Notes: This recommendation earned a B rating because it is based on official policy directives rather than experimental data. The lower bound of the pooled odds ratio sits right at 1.00, and the authors only describe the relationship as “possible,” so it should be viewed as a practical family guideline rather than a guarantee that avoiding screens eliminates myopia risk. The strongest evidence for prevention comes from Recommendation 4 (two hours of outdoor activity daily). Regular eye examinations are also advised for preschoolers: the same document recommends periodic refraction screening for ages 1–3, 4–6, and older to assess remaining far‑sightedness reserve; details are provided in Recommendation 12 (pupil dilation refraction). Finally, a meta‑analysis of 42 studies involving 18,905 participants found that longer screen time correlates with weaker language development (r = −0.14, 95 % CI −0.18 to −0.10). However, watching educational content on screen shows a positive correlation (r = 0.16 and 0.13). This is a correlation, not causation; it simply underscores that substituting screen time for direct interaction with caregivers is less beneficial for language growth. ### 6. Treating myopia as a lasting injury: the higher the prescription, the greater the future risk of retinal detachment, macular degeneration, and glaucoma - Cost: No cost involved. There is nothing specific to do here; the necessary actions are outlined in items 4 and 5 (spending two hours outdoors and managing screen time based on age). - In plain terms: Myopia does not go away on its own, nor does the prescription level decrease. It is far more than simply “wearing glasses.” Compared to people without myopia, those with mild myopia face a risk of myopic macular degeneration roughly 10–15 times higher; for individuals with a prescription of 600 degrees or more, this risk rises by several hundred times. The likelihood of retinal detachment is about three times higher for mild myopia and roughly 13 times higher for severe myopia. Therefore, the earlier a child develops myopia and the faster it progresses, the greater the long-term risks they must face. - Benefit: A systematic review and meta-analysis compiled studies published up to June 2019, grouping participants into three prescription categories: mild (−0.5 to −3.00 D), moderate (−3.00 to −6.00 D), and high (≤−6.00 D, i.e., 600 degrees or more). Compared to people without myopia, the odds ratios for myopic macular degeneration were 13.57 (95% CI 6.18–29.79) for mild myopia, 72.74 (33.18–159.48) for moderate myopia, and 845.08 (230.05–3104.34) for high myopia. For retinal detachment, these odds ratios were 3.15 (1.92–5.17), 8.74 (7.28–10.50), and 12.62 (6.65–23.94) respectively. The odds ratios for posterior subcapsular cataract were 1.56 (1.32–1.84), 2.55 (1.98–3.28), and 4.55 (2.66–7.75) respectively. For open-angle glaucoma, the odds ratio for mild myopia was 1.59 (1.33–1.91), while for moderate and high myopia combined it was 2.92 (1.89–4.52). Among individuals over 60, the odds ratios for visual impairment were 1.71 (1.07–2.74), 5.54 (3.12–9.85), and 87.63 (34.50–222.58) respectively. This aligns with the “Ten Core Principles for Preventing and Controlling Myopia in Children and Adolescents,” which defines high myopia as a prescription of 600 degrees or more; such individuals face significantly higher rates of cataracts, open-angle glaucoma, myopic macular degeneration, retinal detachment, and other vision-threatening conditions. Importantly, “myopia can be prevented and controlled, but not reversed.” - Evidence grade: A - Sources:Haarman AEG, Enthoven CA, Tideman JWL, Tedja MS, Verhoeven VJM, Klaver CCW (2020). The complications of myopia: a review and meta-analysis. Investigative Ophthalmology & Visual Science, 61(4), 49. ; 国家卫生健康委办公厅 (2023). 防控儿童青少年近视核心知识十条（国卫办妇幼函〔2023〕278 号）. - Notes: All studies included in this analysis were observational studies, and the reported odds ratios are unusually large. For instance, the confidence interval for high myopia and myopic macular degeneration spans from 230 to 3104, indicating considerable variation among individual studies; thus these figures should be viewed as rough estimates rather than precise values. Most of these complications tend to appear only in middle or old age, so this is not a situation where immediate harm occurs; rather, it represents a long-term risk that accumulates over decades. Myopia itself is not a disability, and the vast majority of people achieve normal vision after wearing corrective lenses. The purpose of this item is to shift the common perception that “once you have myopia, glasses are all you need” to recognizing that it is worthwhile to delay and control its progression. Information on follow-up examinations after diagnosis can be found in item 12 (pupil dilation and refraction testing). Be wary of products claiming to cure myopia; refer to item 9 (myopia cannot be cured) for further details. ### 7. Take a close look at your child’s annual school health report and follow up on any abnormalities right away - Cost: No cost at all. Under China’s Compulsory Education Law, all school health check fees are covered by school operating budgets, so parents pay nothing extra. - In plain terms: Every year, primary and middle schools conduct one health check for every student. The official guidelines list being overweight, obese, malnourished, having spinal curvature issues, poor eyesight, and dental cavities as key areas that need special attention. These problems are precisely the ones parents tend to put off dealing with. Don’t just glance at your child’s height and weight measurements and then file the report away. If any of these issues show up on the report, take your child to a specialist for a proper check-up that same year — don’t wait until the next annual check. - Benefit: The 2021 Administrative Measures for Health Checks of Primary and Middle School Students requires all such schools to run one health check per year for every enrolled student. The physical exam covers the head, neck, chest, spine, limbs, skin, and lymph nodes, while the eye exam checks external eye condition, distance vision, and refractive errors (degree of myopia or hyperopia). The individual report issued to each student must include all test results, an overall assessment, and tailored health guidance. Overweight, obesity, malnutrition, spinal curvature issues, poor eyesight, and dental cavities are all designated as priority areas for follow-up. Local education authorities are also required to keep records of students with health problems and conduct regular follow-ups. All costs for these compulsory education health checks are paid by school budgets, with no extra charges for parents (issued nationwide in September 2021). - Evidence grade: B - Sources:国家卫生健康委、教育部 (2021). 中小学生健康体检管理办法（2021 年版）（国卫医发〔2021〕29 号）. - Notes: This grade is assigned because the document is a set of administrative rules for schools, not a study on the actual effectiveness of these checks. It guarantees that schools will run annual checks covering the listed items and follow up on any abnormalities, but does not confirm that all identified issues will receive timely intervention. These health checks are only a preliminary screening tool, not a formal diagnosis. For poor eyesight, a pupil dilation refraction test at an ophthalmology clinic is required (see Item 12). For spinal curvature issues, a visit to an orthopedics or spinal surgery specialist is necessary (see Item 2 — do not delay treatment to wait until after exams). Parents are responsible for arranging these follow-up appointments for their children. ### 8. Conducting a depression screening for kids aged 12 to 18 — don’t rely on school mental health assessments as a diagnosis - Cost: Costs range from zero to just a few dozen yuan; this covers filling out a screening questionnaire at a community clinic or hospital outpatient department. Calling the 12355 and 12356 hotlines is completely free. - In plain terms: The U.S. Preventive Services Task Force recommends screening adolescents aged 12 to 18 for major depressive disorder, noting that the overall benefits are moderate and justify the effort. There is insufficient evidence to support screening for kids under 11. Suicide is the second leading cause of death among people aged 10 to 19. School mental health assessments conducted each academic year are population-wide screenings, not diagnostic tools. If a child reports feeling distressed, or shows sudden changes in eating, sleeping, interests, or academic performance, they should be referred to a psychiatrist or clinical psychologist right away. - Benefit: In 2022, the U.S. Preventive Services Task Force issued a recommendation statement advising that adolescents aged 12 to 18 be screened for major depressive disorder; this recommendation falls under Category B, meaning the evidence supporting it is moderate and the benefits are also moderate, making it worthwhile. For children under 11, there is insufficient evidence to support depression screening (an I statement, which indicates a lack of evidence and no formal recommendation). Likewise, evidence regarding both the benefits and risks of screening children and adolescents specifically for suicide risk is also limited (another I statement). The document emphasizes that suicide is the second leading cause of death among 10- to 19-year-olds, and that major depression in youth is closely linked to numerous later issues, including recurrent depressive episodes and other mental disorders, as well as a heightened risk of suicidal thoughts, suicide attempts, and death. China’s “Ten Measures to Further Improve Mental Health Care for Primary and Secondary School Students” calls for establishing a three-tier support system: homeroom teachers, full- and part-time school counselors, and psychiatrists. Each student should undergo a mental health assessment no more than once per academic year. The measures also stress the need to improve referral pathways to mental health specialists and reintegration processes after recovery. Additionally, they highlight the importance of leveraging the 12355 Youth Service Hotline and the 12356 Psychological Assistance Hotline (issued nationwide in October 2025). - Evidence grade: B - Sources:US Preventive Services Task Force (2022). Screening for Depression and Suicide Risk in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. ；教育部办公厅 (2025). 进一步加强中小学生心理健康工作十条措施（教基厅〔2025〕2 号）. - Notes: This B rating reflects the original recommendation strength grading used by the task force, rather than a quantifiable measure of actual effectiveness. It represents a U.S.-based recommendation; no equivalent official screening guidelines currently exist in China. A positive screening result merely indicates the need for a follow-up evaluation — it does not constitute a formal diagnosis. Guidance on handling suicidal thoughts can be found in Section 1, Item 25, while family coping strategies are outlined in Section 29. ### 9. Do not buy products or services claiming to “cure myopia” or “reduce refractive error” - Cost: There is no cost involved; in fact, you save this money by avoiding such purchases. - In plain terms: The State Administration for Market Regulation explicitly states that “under current medical technology, myopia cannot be cured.” Phrases such as “recovery,” “restoration,” “reducing refractive error,” “curing myopia,” “myopia remedy,” and “repairing refractive error” are classified as illegal marketing claims subject to strict enforcement. If you encounter any of these terms, you can safely rule out those products without further comparison. Devices such as eye-care instruments are considered medical devices, and e-commerce platforms must verify whether sellers are qualified to sell them. - Benefit: A notice issued by the General Office of the State Administration for Market Regulation between November 2021 and March 2022 clearly reiterates that “under current medical technology, myopia cannot be cured.” It mandates strict legal action against any marketing of products aimed at preventing or controlling myopia in children and adolescents that employ misleading language like “recovery,” “restoration,” “reducing refractive error,” “curing myopia,” “myopia remedy,” or “repairing refractive error.” The notice also calls for intensified efforts to combat practices that misuse traditional Chinese medicine terminology or theories for deceptive advertising, as well as two specific types of false advertising: using patient testimonials or images to compare pre- and post-treatment outcomes, and making guaranteed claims regarding treatment safety or effectiveness. Additionally, e-commerce platforms are required to rigorously verify the qualifications of sellers offering medical devices such as eye-care instruments and other specialized products (nationwide). - Evidence grade: B - Sources:市场监管总局办公厅 (2021). 关于开展儿童青少年近视防控产品违法违规商业营销宣传专项整治行动的通知. - Notes: This grade is assigned because the basis comes from regulatory determinations during enforcement actions rather than from controlled comparative trials of actual products. However, both health authorities and regulators agree on the statement “Myopia can be prevented and controlled, but it cannot be reversed.” The only two evidence-backed recommendations appear in items 4 (outdoor activities) and 12 (proper eye examinations, glasses fitting, and follow-ups). Information on blue-light-blocking glasses can be found in Section 6. ### 10. Clear rules exist for sleep, homework, sports, and rankings; if schools fail to comply, parents can raise the issue - Cost: No cost involved. All you need is to know these rules so you can bring them up with the school or local education authorities when necessary. The real challenge is simply speaking up about it. - In plain terms: These rules are all laid out in writing: elementary students must get 10 hours of sleep per day, junior high students 9 hours, and high school students 8 hours. Elementary classes generally start no earlier than 8:20 a.m., and junior high classes no earlier than 8:00 a.m. In 2025, an additional requirement was added that schools must provide at least 2 hours of combined physical activity per day, and students must not be ranked based on test scores. If your child consistently fails to get enough sleep, use these rules as a reference point rather than blaming the child for being slow to get ready. - Benefit: The *Notice on Further Strengthening Sleep Management for Primary and Secondary School Students* stipulates that elementary students must get 10 hours of sleep daily, junior high students 9 hours, and high school students 8 hours. Elementary classes generally start no earlier than 8:20 a.m., and junior high classes no earlier than 8:00 a.m. Schools are prohibited from requiring students to arrive at school early for mandatory educational activities. Elementary students must go to bed no later than 9:20 p.m., junior high students no later than 10:00 p.m., and high school students no later than 11:00 p.m. After-school tutoring programs must end no later than 8:30 p.m., and online live tutoring sessions must end no later than 9:00 p.m. From 10:00 p.m. to 8:00 a.m. the next day, game services for minors are banned nationwide (issued March 2021). The *Ten Measures for Further Strengthening Mental Health Work Among Primary and Secondary School Students* contains several additional provisions. All schools are required to ensure students get at least 2 hours of combined physical activity per day, and the practice of offering 15-minute recess periods is encouraged. Students must not be ranked based on test scores, and repetitive, punitive homework assignments are strictly prohibited. A nationwide initiative launched in October 2025 encourages schools to designate one day per week as a “homework-free day.” - Evidence grade: B - Sources:教育部办公厅 (2021). 关于进一步加强中小学生睡眠管理工作的通知（教基厅函〔2021〕11 号）. ；教育部办公厅 (2025). 进一步加强中小学生心理健康工作十条措施（教基厅〔2025〕2 号）. - Notes: Both documents were issued by relevant education authorities. Implementation varies widely across different regions and schools, which is why this item is rated B. Their main purpose is to help parents understand what schools are obligated to provide, so they have solid grounds to bring these issues up when needed. Information on adult sleep needs can be found in Sections 2 and 3. ### 11. Parents can request a temporary leave of absence for their child; the school must retain the child’s enrollment status for up to one year - Cost: No cost involved. Parents or other legal guardians must submit a formal request to the school. The main challenge is first accepting that the child needs a break from school for a while. - In plain terms: A temporary leave of absence is a fully established procedure. Parents or legal guardians submit a request, which the school then approves and forwards to the relevant education authorities for final authorization. Each request is valid for no more than one year; if the child still needs time off after that, a new request must be filed. During this period, the school is legally required to keep the child’s enrollment status intact. Therefore, the idea that taking a leave of absence “ruins” a child’s education has no basis in current policy. Exact implementation details vary by province; parents should contact the school’s academic affairs office or local education bureau for specifics. - Benefit: Article 16 of the “Administrative Measures for Student Enrollment Records of Primary and Secondary School Students” outlines the proper process for granting a temporary leave of absence. Parents or legal guardians initiate the request, which the school then forwards to higher education authorities for approval. Upon the child’s return, the school must promptly handle all necessary re-enrollment paperwork. Each approved leave cannot exceed one year; if further time off is required, a new application must be submitted. While the child is away, the school must maintain their enrollment status, effectively preserving their place in the system. Detailed procedures for leave and re-enrollment are determined by provincial education authorities (nationwide, issued January 2025). Additionally, the “Ten Measures for Strengthening Mental Health Support for Primary and Secondary School Students” encourages establishing clear pathways for students recovering from mental health conditions to return to school, while also mandating that schools develop emergency response plans for psychological crises on campus. - Evidence grade: B - Sources:教育部 (2025). 中小学生学籍管理办法（教基〔2025〕1 号，第十六条）. ；教育部办公厅 (2025). 进一步加强中小学生心理健康工作十条措施（教基厅〔2025〕2 号）. - Notes: Before applying, be sure to clarify three key points: what kind of medical documentation is required, how the child’s enrollment status is tracked while on leave, and whether they’ll return to their original grade level or be placed in a lower one. This recommendation is graded B because while a national framework exists, specific eligibility criteria, required paperwork, and re-enrollment protocols are all determined locally by provincial education authorities. Furthermore, the “Regulations on Protecting Schooling Rights for Minors” requires all compulsory education schools to maintain records of students who drop out, take extended leaves, or are absent for prolonged periods; this means the procedure is already standard practice within the system, rather than an exception granted solely to your child. ### 12. If poor vision is detected, go to the hospital for cycloplegic refraction and follow up at the recommended intervals as advised by the doctor - Cost: The examination and glasses fitting typically cost several tens to several hundred yuan. After using the eye drops, children may be sensitive to light and have blurry near vision; it usually takes half a day to a couple of days for this to subside. - In plain terms: Cycloplegic refraction involves using special eye drops that relax the eye’s focusing muscles, allowing an accurate measurement of refractive errors. This test is performed in hospitals and is the most reliable method for diagnosing myopia. The Health Commission confirms these drops do not harm healthy eyes and that vision returns to normal after they wear off. Do not rely on quick computerized refraction tests at optical shops for diagnosis, and do not withhold glasses from children out of fear that it will worsen their myopia. - Benefit: The “Ten Core Principles for Preventing and Controlling Myopia in Children and Adolescents” outlines how cycloplegic refraction works: it uses a cycloplegic agent to relax the focusing muscles before measuring refractive errors. This medical procedure is regarded as the gold standard for diagnosing myopia, providing the most accurate results. The drops themselves are safe for healthy eyes; side effects such as light sensitivity and blurred near vision are temporary and resolve after treatment ends. Once myopia is confirmed, timely corrective measures—such as wearing appropriate glasses—are essential. Proper glasses can correct vision and slow progression of the condition. Children aged preschool through elementary school should have their vision rechecked every 3–6 months, while middle and high school students should be checked every 6–12 months, depending on individual needs. Regular refractive screenings are also recommended at ages 1–3, 4–6, and thereafter to monitorhyperopia reserve (远视储备量, "farsightedness reserve") (the amount of reserve focusing ability). (National guidelines issued July 2023) - Evidence grade: B - Sources:国家卫生健康委办公厅 (2023). 防控儿童青少年近视核心知识十条（国卫办妇幼函〔2023〕278 号）. - Notes: This grade is assigned because the information originates from official public health publications rather than original research containing specific quantitative data. Because high myopia increases the risk of complications such as retinal detachment, follow-up visits serve purposes beyond simply updating prescriptions. “Poor vision” noted during school screenings is merely an initial indicator; a full ophthalmologic evaluation at a hospital is still required, as detailed in item 7. ### 13. Pit and fissure sealants applied after permanent molars emerge - Cost: Each application costs just a few dozen to a couple of hundred yuan — specifically, between 100 and 200 yuan per tooth. No anesthesia is needed, no tooth grinding is required, and the whole procedure takes only a few minutes. Many regions offer free sealant programs for children who meet the age criteria. - In plain terms: Pit and fissure sealants involve filling the grooves on the chewing surfaces of molars with a special resin so food particles can’t get trapped there. After two years, the chance of developing cavities on sealed teeth drops to roughly one‑eighth of what it would be without sealants. Without sealants, about 16% of tooth surfaces develop decay; with sealants, that figure falls to only about 5%. The protective effect remains evident even four years after application. - Benefit: This conclusion comes from 38 separate trials involving 7,924 children aged 5–16, all selected and pooled by Cochrane according to strict methodological standards. The studies compared children who received resin‑based sealants with those who did not. For first permanent molars in the 5–10 age group, the odds ratio after 24 months was 0.12 (95% CI 0.08–0.19), meaning the risk of decay was roughly one‑eighth that of untreated teeth. This result is based on seven trials with 1,548 participants randomly assigned and 1,322 actually examined; the overall evidence quality is rated as moderate. If the untreated control group shows 16% decayed surfaces after two years, the sealed group shows only 5.2% (range 3.13%–7.37%). When the control group rate reaches 40%, the sealed group still stays at 6.25% (3.84%–9.63%); at a 70% control rate, the sealed group remains at 19% (12.3%–27.2%). After 48–54 months the odds ratio remains low at 0.21 (0.16–0.28), indicating a risk roughly one‑fifth that of untreated teeth. Authors conclude that resin sealants reduce cavity formation by 11%–51% compared with no sealants after two years. No adverse effects were reported in any of the four trials that monitored side‑effects; however, there is insufficient evidence to determine whether glass‑ionomer sealants perform better than other types. - Evidence grade: A - Sources:Ahovuo-Saloranta A, et al. (2017). Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews. - Notes: The first permanent molars — teeth that never get replaced — typically appear around age 6, with the second set emerging near age 12. Sealants should be applied as soon as these molars emerge and before any decay sets in; once a cavity has formed, sealants can no longer be used and filling is required instead. Many regions provide free sealant programs for eligible children, so it’s worth checking with the local Chinese CDC or community health centers. No nationwide document with exact coverage criteria or age limits could be identified for this section, so those details are omitted here. Preventing dental caries remains a key focus of school‑age health screenings; see Section 7 for further information. ### 14. If a child loves playing games, first check whether sleep, homework, and outdoor activities are being crowded out — don’t just focus on how long they play - Cost: No cost at all. Simply keep an eye each week on what time your child goes to bed, whether they’ve turned in their homework, and if they’ve gotten any outdoor time. - In plain terms: Only about two or three out of every hundred kids truly meet the criteria for “gaming disorder.” If surveys use very low thresholds and target only teenagers, the rate naturally appears much higher. Real usage data from game companies shows almost no link between how much a child plays and how happy they feel. By law, minors may play games only from 8 PM to 9 PM on Fridays, Saturdays, Sundays, and public holidays. - Benefit: One meta-analysis combined results from 53 studies conducted in 17 countries, involving 226,247 participants. The overall prevalence of gaming disorder was 3.05% (95% CI 2.38–3.91), which represents a reliable range. When only studies with stricter sampling criteria were considered, the rate dropped to 1.96%. Large differences among studies stem largely from the specific questionnaires used. Small sample sizes and low threshold scores also tend to inflate reported rates. Another study examined actual gameplay data from 38,935 players over six weeks, comparing it with self‑reported happiness levels; it found virtually no evidence that gaming time affects happiness. Chinese regulations require game providers to limit minors to one hour of play each day on Fridays, Saturdays, Sundays, and holidays, from 8 PM to 9 PM (effective 2021). - Evidence grade: B - Sources:Stevens MW, Dorstyn D, Delfabbro PH, King DL. (2021). Global prevalence of gaming disorder: A systematic review and meta-analysis. Australian and New Zealand Journal of Psychiatry, 55(6), 553–568. ；Vuorre M, Johannes N, Magnusson K, Przybylski AK. (2022). Time spent playing video games is unlikely to impact well-being. Royal Society Open Science, 9(7), 220411. ；国家新闻出版署 (2021). 关于进一步严格管理切实防止未成年人沉迷网络游戏的通知（国新出发〔2021〕14 号）. - Notes: This grade is assigned because the prevalence figure varies widely depending on the questionnaire used, and the happiness study followed participants for only six weeks. The main downside of excessive gaming is that it often displaces sleep and outdoor activity. Specific limits on sleep are outlined in Section 10 (Sleep, Homework, Physical Activity); outdoor time requirements appear in Section 4 (Two hours of outdoor activity daily). Screen time limits for non‑educational use are detailed in Section 5 (No more than one hour per day). Issues related to in‑game purchases and refunds are addressed in Section 5, Item 9 (Children making in‑app purchases). If a child’s academic performance, sleep quality, and family relationships all deteriorate despite repeated advice, a visit to a psychiatrist or pediatric psychologist is advisable. The primary beneficiaries of these guidelines are the children themselves. ### 15. If a child says they’re attracted to the same sex, don’t scold them, don’t kick them out, and don’t send them for “conversion therapy”: how your family reacts can affect whether they attempt suicide - Cost: There is no financial cost. The real challenge is for parents to manage their own emotions so they don’t lash out in the moment. - In plain terms: Among Chinese middle‑school students, those who are attracted only to the opposite sex are far less likely to attempt suicide than peers who are attracted to the same sex or both sexes. International research shows that adolescents who face strong rejection from their families are much more prone to suicide attempts; those whose parents send them for “conversion therapy” are at the highest risk. - Benefit: A nationwide survey of 150,822 students from grades 7‑12 in 506 schools across seven provinces found that in the past year, 2.2 % of boys attracted only to girls attempted suicide, compared with 6.9 % of boys attracted only to boys and 12.2 % of boys attracted to both sexes — roughly 3‑5.5 times higher. For girls the figures were 3.1 %, 8.9 % and 10.9 % respectively. After adjusting for age, academic pressure, family income and bullying, the odds ratios for boys were 3.13 (95 % CI 2.28‑4.28) and 3.83 (95 % CI 2.85‑5.14). A meta‑analysis of 35 studies reported an overall odds ratio of 3.50 (95 % CI 2.98‑4.12) for sexual‑minority youth attempting suicide. In the U.S., a study of 224 gay and bisexual young adults aged 21‑25 found that those who recalled strong family rejection during adolescence had an odds ratio of 8.4 for suicide attempts compared with peers with little rejection. Other research shows odds ratios of 3.08 (95 % CI 1.39‑6.83) when parents tried to change their child’s sexual orientation, and 5.07 (95 % CI 2.38‑10.79) when parents referred them to therapists or religious counselors. - Evidence grade: B - Sources:Huang Y, Li P, Guo L, et al. (2018). Sexual minority status and suicidal behaviour among Chinese adolescents: a nationally representative cross-sectional study. BMJ Open, 8(8), e020969. ；di Giacomo E, Krausz M, Colmegna F, Aspesi F, Clerici M. (2018). Estimating the Risk of Attempted Suicide Among Sexual Minority Youths: A Systematic Review and Meta-analysis. JAMA Pediatrics, 172(12), 1145–1152. ；Ryan C, Huebner D, Diaz RM, Sanchez J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346–352. ；Ryan C, Toomey RB, Diaz RM, Russell ST. (2020). Parent-Initiated Sexual Orientation Change Efforts With LGBT Adolescents: Implications for Young Adult Mental Health and Adjustment. Journal of Homosexuality, 67(2), 159–173. ；全国人大常委会 (2024 年修正). 未成年人保护法（第十七条）. ；全国人大常委会 (2015). 反家庭暴力法（第二条）. - Notes: This grade is assigned because the data come from single‑time surveys and family rejection is recalled by adults; they demonstrate an association but cannot prove causation. Parents need not immediately accept their child’s orientation; the priority is to avoid any harmful actions. Legally, parents must not abuse, neglect or inflict domestic violence on their children; constant verbal abuse and intimidation also count as domestic violence. If a child appears depressed or says they want to die, call 12356 as described in Section 1, Item 25. A depression screening as outlined in Section 1, Item 8 can also be arranged at a psychiatric clinic. For reasons why “conversion therapy” must be avoided, see Section 6, Item 28. Ultimately, protecting your child benefits both them and you. ### 16. Do not hit your child, and do not yell or call them stupid: children who are often hit or verbally abused show more behavior and emotional problems - Cost: No money. The hard part is stopping your hands and mouth in the heat of the moment and switching to non-violent discipline. What to switch to is covered in item 17 in this section (parenting classes that teach concrete skills). - In plain terms: Children who are often physically punished show more aggression and psychological problems, feel more distant from parents, and receive harsher beating. Whether spanking makes a child obey on the spot is unclear in the evidence. Adolescents who are often yelled at or called stupid at age 13 show more misconduct and depression the next year; warm parenting does not cancel that link. - Benefit: For physical punishment, one meta-analysis counted only open-hand spanking of the buttocks or limbs. It pooled 75 studies with 111 effect sizes and 160,927 children. Of 17 outcomes, 13 were significantly associated with spanking, all in harmful directions. Cohen’s d: 0.2 small, 0.5 medium. Childhood aggression d = 0.37 (95% CI 0.13–0.61). Externalizing problems 0.41 (hitting, rule-breaking). Internalizing 0.24 (anxiety, depression). Mental health problems 0.53. Poor parent–child relationship 0.51. Low self-esteem 0.15. Poor cognitive ability 0.17. Parental physical abuse 0.64. Adult antisocial behavior 0.36. Adult mental health 0.24. Pooled across 111 effects d = 0.33 (0.29–0.38). Immediate compliance was not clearly linked (d = 0.14, −0.19–0.47), with only 5 effect sizes. Another review of 69 longitudinal studies found spanking reliably predicted later behavior problems and no long-term benefits; 7 studies counted frequency, 5 found more spanking linked to worse outcomes. For yelling: a U.S. study followed 976 two-parent families. Frequent yelling, cursing, or calling the child stupid or lazy at age 13 predicted more misconduct and depressive symptoms between ages 13 and 14. Parental warmth did not offset the association; the reverse also held — more misconduct at 13 predicted more yelling later. Under China’s Anti–Domestic Violence Law Article 2, domestic violence includes beating, binding, mutilation, restricting personal freedom, and habitual verbal abuse or intimidation. Article 12 requires guardians to practice civilized family education. When parents harm a child’s rights, neighborhood committees must counsel and stop them and report serious cases to police. Public security, procuratorate, and courts may admonish parents and order family-education guidance (nationwide). - Evidence grade: A - Sources:Gershoff ET, Grogan-Kaylor A. (2016). Spanking and child outcomes: Old controversies and new meta-analyses. Journal of Family Psychology, 30(4), 453–469. ；Heilmann A, Mehay A, Watt RG, et al. (2021). Physical punishment and child outcomes: a narrative review of prospective studies. Lancet, 398(10297), 355–364. ；Wang MT, Kenny S. (2014). Longitudinal links between fathers' and mothers' harsh verbal discipline and adolescents' conduct problems and depressive symptoms. Child Development, 85(3), 908–923. ；Ferguson CJ. (2013). Spanking, corporal punishment and negative long-term outcomes: a meta-analytic review of longitudinal studies. Clinical Psychology Review, 33(1), 196–208. ；Larzelere RE, Kuhn BR. (2005). Comparing child outcomes of physical punishment and alternative disciplinary tactics: a meta-analysis. Clinical Child and Family Psychology Review, 8(1), 1–37. ；全国人大常委会 (2015). 反家庭暴力法（第二、十二条）. ；全国人大常委会 (2024 年修正). 未成年人保护法（第十一、十七、一百一十八条）. ；全国人大常委会 (2021). 家庭教育促进法（第二十三、五十三条）. - Notes: Controversial. These studies are almost all observational, not randomized trials, so causation is unclear. In the spanking meta-analysis, 72% of studies were cross-sectional or relied on recall. A meta-analysis of longitudinal studies found that after adjusting for prior child behavior, links to externalizing problems fell to 0.07 and internalizing to 0.10; those authors judged effects small. Another meta-analysis found “conditional” spanking outperformed 10 of 13 alternative discipline methods for reducing defiance and antisocial behavior, but severe or predominant spanking did worse than alternatives. Critics and supporters agree that heavy, frequent hitting and verbal abuse are worse. Occasional single spank or shout is not explicitly labeled domestic violence in the law, which names beating and habitual verbal abuse or intimidation. Main beneficiaries are children. If someone else in the family hits the child, see Section 8, item 43 (personal safety protection orders). Anyone may dissuade or report chronic child abuse to police, civil affairs, or education authorities; for strangers’ households, calling 110 or telling the neighborhood committee is enough — do not force your way in. ### 17. If parenting feels out of control and you keep hitting or yelling, take a class that teaches concrete parenting skills - Cost: Parent schools run by schools, kindergartens, and communities are public and free. Evidence-based programs meet weekly or biweekly for 1–2 hours per session, for 4 to 24 weeks. You must practice at home. The hard part is finishing and practicing daily. - In plain terms: Parenting programs that teach specific techniques reduce children’s hitting and rule-breaking in randomized trials, and parents’ mood improves. Parents also hit and yell less — strongest right after the course, still present one to two years later but much smaller. Shanghai has run similar trials with positive results. - Benefit: Cochrane pooled 13 trials, 10 randomized, 1,078 parents of children aged 3–12 with behavior problems. After training, children’s behavior problems decreased. Parent report SMD −0.53 (95% CI −0.72 to −0.34); independent raters −0.44 (−0.77 to −0.11). SMD matches d; 0.5 is medium. Parent mental health improved −0.36 (−0.52 to −0.20). Harsh or negative parenting decreased: parent report −0.77 (−0.96 to −0.59), independent −0.42 (−0.67 to −0.16). Authors describe these as short-term effects. Another meta-analysis screened 346 randomized trials; 60 measured hitting or yelling across 22 countries. Hitting/yelling decreased immediately post-course d = −0.46 (−0.59 to −0.33). At 1–6 months −0.24 (−0.37 to −0.11). At 7–24 months −0.18 (−0.34 to −0.02), fading over time. Most data are parent-reported. In China, Shanghai randomized 81 parents to Triple P group training versus waitlist; after training and at 6 months, child adjustment, parenting practices, and parent mood were better than waitlist. A rural kindergarten trial with 191 caregivers: self-paced online lessons plus two group discussions versus book only; after two weeks self-reported child abuse behaviors were about 33% lower (IRR 0.67). At three months children’s behavior problems were lower (d = −0.40). The Family Education Promotion Law requires parents to study family-education knowledge. Schools and kindergartens may run parent schools with regular public guidance; neighborhood committees may run community parent schools. Provincial-level governments must provide public online parent schools and hotlines. Family-education guidance institutions may not run for-profit training (nationwide, effective 1 January 2022). - Evidence grade: A - Sources:Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database of Systematic Reviews, (2), CD008225. ；Backhaus S, Leijten P, Jochim J, Melendez-Torres GJ, Gardner F. (2023). Effects over time of parenting interventions to reduce physical and emotional violence against children: a systematic review and meta-analysis. eClinicalMedicine, 60, 102003. ；Guo M, Morawska A, Sanders MR. (2016). A Randomized Controlled Trial of Group Triple P With Chinese Parents in Mainland China. Behavior Modification, 40(6), 825–851. ；Wang W, Zhang H. (2026). A self-directed parenting program to reduce the risk of child maltreatment in rural China: A cluster randomized controlled trial. Child Abuse & Neglect, 173, 107937. ；全国人大常委会 (2021). 家庭教育促进法（第十八、二十五、三十一、三十八、四十条）. - Notes: Grade A from Cochrane and pooled randomized trials. Shared features: instructors teach concrete skills (play with the child, praise, rewards, discipline); parents practice and get homework. Programs that only handed out materials or only discussed were excluded, so evidence does not cover one-off lectures. Content of local public parent schools varies and may not match this model — look for multi-week courses with practiced skills. Names often include Triple P, Incredible Years, Parent–Child Interaction Therapy (PCIT). This book does not endorse specific providers or paid products. Reduced hitting fades after one to two years; keep practicing after the course ends. Beneficiaries are the child and you. If the child already has severe emotional problems, see a psychiatrist or child psychologist — item 8 in this section (depression screening).