Early identification of mental health problems in schools: The status of instrumentation

Contextual determinants associated with children's and adolescents' mental health care utilization: a systematic review

Determinants at the contextual level are important for children's and adolescents' mental health care utilization, as this is the level where policy makers and care providers can intervene to improve access to and provision of care. The objective of this review was to summarize the evidence on contextual determinants associated with mental health care utilization in children and adolescents. A systematic literature search in five electronic databases was conducted in August 2021 and retrieved 6439 unique records. Based on eight inclusion criteria, 74 studies were included. Most studies were rated as high quality (79.7%) and adjusted for mental health problems (66.2%). The determinants that were identified were categorized into four levels: organizational, community, public policy or macro-environmental. There was evidence of a positive association between mental health care utilization and having access to a school-based health center, region of residence, living in an urban area, living in an area with high accessibility of mental health care, living in an area with high socio-economic status, having a mental health parity law, a mental health screening program, fee-for-service plan (compared to managed care plan), extension of health insurance coverage and collaboration between organizations providing care. For the other 35 determinants, only limited evidence was available. To conclude, this systematic review identifies ten contextual determinants of children's and adolescents' mental health care utilization, which can be influenced by policymakers and care providers. Implications and future directions for research are discussedPROSPERO ID: CRD42021276033.

The Brief Evaluation of Adolescents and Children Online (BEACON): Psychometric development of a mental health screening measure for school students

This paper describes the development and psychometric evaluation of a brief self-report measure (BEACON) to inform universal mental health screening in schools. Items assess symptoms and impairment associated with anxiety and attention/hyperactivity problems (grades 4-11) as well as depression and eating difficulties (grades 6-11), with optional items for suicidality and self-harm (grades 7-11). Initial item examination based on Item Response Theory (IRT) and classical test theory involved 3844 students in grades 4 through 11 (Study 1) and identified 18 items for grades 4-5 and 31 items for grades 6-11 that fulfilled pre-set criteria. Study 2 extended testing with 10,479 students in grades 4-11 and added an additional four items assessing impairment associated with eating difficulties for older students (grades 6-11) creating a total of 35 items for grades 6-11. All items, for both grade-level versions, met the pre-set criteria for IRT and classical test theory analysis supporting their strength in the measurement of the dimensions of concern. The measure showed good reliability (subscale alphas .87 to .95). Validity was also demonstrated against standard symptom measures, school grades, school absenteeism, and help-seeking. The BEACON appears to be a psychometrically sound measure to use in the first stage of school-based screening for mental health problems.

Improving alcohol and substance use screening in school-age children: translation, adaptation and psychometric evaluation of the CRAFFT tool for Lumasaaba, Uganda

BACKGROUND

Children at risk of substance use disorders (SUD) should be detected using brief structured tools for early intervention. This study sought to translate and adapt the Car, Relax, Alone, Forget, Family/Friends, Trouble (CRAFFT) tool to determine its diagnostic accuracy, and the optimum cut-point to identify substance use disorders (SUD) risk in Ugandan children aged 6 to 13 years.

METHODS

This was a sequential mixed-methods study conducted in two phases. In the first qualitative phase, in Kampala and Mbale, the clinician-administered CRAFFT tool version 2.1 was translated into the local Lumasaaba dialect and culturally adapted through focus group discussions (FGDs) and in-depth interviews, in collaboration with the tool's authors. Expert reviews and translations by bilingual experts provided insights on linguistic comprehensibility and cultural appropriateness, while pilot testing with the target population evaluated the tool's preliminary effectiveness. In the second phase, the CRAFFT tool, adapted to Lumasaaba, was quantitatively validated against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) for diagnosing SUD in Mbale district, through a survey. Participants, chosen randomly from schools stratified according to ownership, location, and school size, were assessed for the tool's reliability and validity, including comparisons to the MINI KID as the Gold Standard for diagnosing SUD. Data were analyzed using STATA-15. Receiver-operating-characteristic analysis was performed to determine the sensitivity, specificity, and criterion validity of the CRAFFT with the MINI-KID.

RESULTS

Of the 470 children enrolled, 2.1% (n = 10) had missing data on key variables, leaving 460 for analysis. The median age and interquartile range (IQR) was 11 (9-12) years and 56.6% were girls. A total of 116 (25.2%) children had consumed alcohol in the last twelve-month period and 7 (1.5%) had used other substances. The mean CRAFFT score for all the children (n = 460) was 0.32 (SD 0.95). The prevalence of any alcohol use disorder (2 or more positive answers on the MINI KID) in the last 12 months was 7.2% (n = 32). The Lumasaaba version of the CRAFFT tool demonstrated good internal consistency (Cronbach's α = 0.86) and inter-item correlation (Spearman correlation coefficient of 0.84 (p < 0.001). At a cut-off score of 1.00, the CRAFFT had optimal sensitivity (91%) and specificity (92%) (Area Under the Curve (AUC) 0.91; 95% CI 0.86-0.97) to screen for SUD. A total of 62 (13.5%) had CRAFFT scores of > 1.

CONCLUSION

The Lumasaaba version of the CRAFFT tool has sufficient sensitivity and specificity to identify school-age children at risk of SUD.

Digital Phenotypes for Early Detection of Internet Gaming Disorder in Adolescent Students: Explorative Data-Driven Study

BACKGROUND

Limited awareness, social stigma, and access to mental health professionals hinder early detection and intervention of internet gaming disorder (IGD), which has emerged as a significant concern among young individuals. Prevalence estimates vary between 0.7% and 15.6%, and its recognition in the International Classification of Diseases, 11th Revision and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition underscores its impact on academic functioning, social isolation, and mental health challenges.

OBJECTIVE

This study aimed to uncover digital phenotypes for the early detection of IGD among adolescents in learning settings. By leveraging sensor data collected from student tablets, the overarching objective is to incorporate these digital indicators into daily school activities to establish these markers as a mental health screening tool, facilitating the early identification and intervention for IGD cases.

METHODS

A total of 168 voluntary participants were engaged, consisting of 85 students with IGD and 83 students without IGD. There were 53% (89/168) female and 47% (79/168) male individuals, all within the age range of 13-14 years. The individual students learned their Korean literature and mathematics lessons on their personal tablets, with sensor data being automatically collected. Multiple regression with bootstrapping and multivariate ANOVA were used, prioritizing interpretability over predictability, for cross-validation purposes.

RESULTS

A negative correlation between IGD Scale (IGDS) scores and learning outcomes emerged (r166=-0.15; P=.047), suggesting that higher IGDS scores were associated with lower learning outcomes. Multiple regression identified 5 key indicators linked to IGD, explaining 23% of the IGDS score variance: stroke acceleration (β=.33; P<.001), time interval between keys (β=-0.26; P=.01), word spacing (β=-0.25; P<.001), deletion (β=-0.24; P<.001), and horizontal length of strokes (β=-0.21; P=.02). Multivariate ANOVA cross-validated these findings, revealing significant differences in digital phenotypes between potential IGD and non-IGD groups. The average effect size, measured by Cohen d, across the indicators was 0.40, indicating a moderate effect. Notable distinctions included faster stroke acceleration (Cohen d=0.68; P=<.001), reduced word spacing (Cohen d=.57; P=<.001), decreased deletion behavior (Cohen d=0.33; P=.04), and longer horizontal strokes (Cohen d=0.34; P=.03) in students with potential IGD compared to their counterparts without IGD.

CONCLUSIONS

The aggregated findings show a negative correlation between IGD and learning performance, highlighting the effectiveness of digital markers in detecting IGD. This underscores the importance of digital phenotyping in advancing mental health care within educational settings. As schools adopt a 1-device-per-student framework, digital phenotyping emerges as a promising early detection method for IGD. This shift could transform clinical approaches from reactive to proactive measures.

Empowering School Staff to Support Pupil Mental Health Through a Brief, Interactive Web-Based Training Program: Mixed Methods Study

BACKGROUND

Schools in the United Kingdom and elsewhere are expected to protect and promote pupil mental health. However, many school staff members do not feel confident in identifying and responding to pupil mental health difficulties and report wanting additional training in this area.

OBJECTIVE

We aimed to explore the feasibility of Kognito's At-Risk for Elementary School Educators, a brief, interactive web-based training program that uses a simulation-based approach to improve school staff's knowledge and skills in supporting pupil mental health.

METHODS

We conducted a mixed methods, nonrandomized feasibility study of At-Risk for Elementary School Educators in 6 UK primary schools. Our outcomes were (1) school staff's self-efficacy and preparedness to identify and respond to pupil mental health difficulties, (2) school staff's identification of mental health difficulties and increased risk of mental health difficulties, (3) mental health support for identified pupils (including conversations about concerns, documentation of concerns, in-class and in-school support, and referral and access to specialist mental health services), and (4) the acceptability and practicality of the training. We assessed these outcomes using a series of questionnaires completed at baseline (T1), 1 week after the training (T2), and 3 months after the training (T3), as well as semistructured qualitative interviews. Following guidance for feasibility studies, we assessed quantitative outcomes across time points by comparing medians and IQRs and analyzed qualitative data using reflexive thematic analysis.

RESULTS

A total of 108 teachers and teaching assistants (TAs) completed T1 questionnaires, 89 (82.4%) completed T2 questionnaires, and 70 (64.8%) completed T3 questionnaires; 54 (50%) completed all 3. Eight school staff members, including teachers, TAs, mental health leads, and senior leaders, participated in the interviews. School staff reported greater confidence and preparedness in identifying and responding to mental health difficulties after completing the training. The proportion of pupils whom they identified as having mental health difficulties or increased risk declined slightly over time (medianT1=10%; medianT2=10%; medianT3=7.4%), but findings suggested a slight increase in accuracy compared with a validated screening measure (the Strengths and Difficulties Questionnaire). In-school mental health support outcomes for identified pupils improved after the training, with increases in formal documentation and communication of concerns as well as provision of in-class and in-school support. Referrals and access to external mental health services remained constant. The qualitative findings indicated that school staff perceived the training as useful, practical, and acceptable.

CONCLUSIONS

The findings suggest that brief, interactive web-based training programs such as At-Risk for Elementary School Educators are a feasible means to improve the identification of and response to mental health difficulties in UK primary schools. Such training may help address the high prevalence of mental health difficulties in this age group by helping facilitate access to care and support.

The Hummingbird Project year 2: decreasing distress and fostering flourishing in a pragmatic pre-post study

Multi-component Positive Psychology Interventions (mPPIs) in secondary schools have been shown to improve mental health outcomes for young people. The Hummingbird Project mPPI is a six-week program of workshops designed to introduce a variety of positive psychology (PP) concepts to secondary school-aged children in schools to improve well-being, resilience, and hope. The effects on mental distress, however, were not explored. The current study, therefore, was designed to replicate the effects of the Hummingbird Project mPPI on positive mental health and to also explore the effects on symptoms of mental distress. Secondary school-aged children (N = 614; mean age = 11.46 years) from a sample of secondary schools located across the North West of England (N = 7) participated in the study; the majority of children were in Year 7 (94%). The PP concepts explored included happiness, hope, resilience, mindfulness, character strengths, growth mindset, and gratitude. The results showed significant improvements associated with the mPPI in well-being (as measured by the World Health Organization Well-Being Index; WHO-5), hope (as measured by the Children's Hope Scale; CHS), and symptoms of mental distress (as measured by the Young Person's Clinical Outcomes in Routine Evaluation; YP-CORE) from pre- to post-intervention. While acknowledging the limits due to pragmatic concerns regarding the implementation of a control group, the effectiveness of the Hummingbird Project mPPI on well-being was replicated alongside reducing the symptoms of mental distress. Future evaluation, however, will need to implement more robust designs and consider follow-up duration to assess the longer-term effects of the Hummingbird Project mPPI.

Dynamic clustering via branched deep learning enhances personalization of stress prediction from mobile sensor data

College students experience ever-increasing levels of stress, leading to a wide range of health problems. In this context, monitoring and predicting students' stress levels is crucial and, fortunately, made possible by the growing support for data collection via mobile devices. However, predicting stress levels from mobile phone data remains a challenging task, and off-the-shelf deep learning models are inapplicable or inefficient due to data irregularity, inter-subject variability, and the "cold start problem". To overcome these challenges, we developed a platform named Branched CALM-Net that aims to predict students' stress levels through dynamic clustering in a personalized manner. This is the first platform that leverages the branching technique in a multitask setting to achieve personalization and continuous adaptation. Our method achieves state-of-the-art performance in predicting student stress from mobile sensor data collected as part of the Dartmouth StudentLife study, with a ROC AUC 37% higher and a PR AUC surpassing that of the nearest baseline models. In the cold-start online learning setting, Branched CALM-Net outperforms other models, attaining an average F1 score of 87% with just 1 week of training data for a new student, which shows it is reliable and effective at predicting stress levels from mobile data.

Exposure to Intimate-Partner Violence and Resilience Trajectories of Adolescents: A Two-Wave Longitudinal Latent Transition Analysis

Despite the serious emotional and social consequences of adolescents' exposure to intimate-partner violence (IPV) and the high prevalence of this exposure, few analyses have focused on person-centered models or considered psychological IPV. Studies that address exposure to violence tend to focus on physical IPV. Therefore, in this study, we examine (across two waves) the trajectories of resilience among adolescents who have witnessed psychological IPV by conducting a latent transition analysis and predicting class membership through socio-demographic and individual-level protective factors. Using a sample of 879 (T1, fall 2020) and 770 (T2, spring 2022) adolescent Swiss students with mean ages of 11.74 (SD = 0.64) and 13.77 (SD = 0.53), we identified four distinct time-invariant resilience classes: comorbid-frustrated, internalizing-frustrated, comorbid-satisfied, and resilient. The classes characterized by some level of psychopathological symptoms and basic psychological-needs frustration were the most stable over time. Furthermore, we found the four typical resilience trajectories: recovery, chronic, delayed, and improving. Gender, socioeconomic background, and protective factors showed a significant prediction of class membership in wave 1, highlighting the importance of increasing sensitivity to psychological-IPV exposure on the one hand, and reinforcing the relevance of prevention in schools regarding the promotion of protective factors on the other.

Teachers' perceptions of the barriers to assessment of mental health in schools with implications for educational policy: A systematic review

BACKGROUND

Assessment of mental health in schools has garnered increased interest in recent years. Children spend a large proportion of their waking hours in schools. Teachers can act as gatekeepers by playing a key role in identifying children with mental health difficulties in the classroom and making the necessary onward referrals to external services. The prevalence of mental health difficulties, their impact on schooling (and beyond) and the importance of early intervention means that it is incumbent on schools to identify and support potentially affected children.

AIMS

Previous reviews focused on mental health interventions in schools; however, this review focuses on the assessment of mental health in schools and on teachers' perceptions of this, as such a review is still lacking. Therefore, the study fills a gap in the existing literature while also providing new, highly relevant evidence that may inform policy making in this area.

COMPOSITION OF STUDIES INCLUDED IN THIS REVIEW

This review included 19 studies. Five studied teachers exclusively at primary/elementary level, and seven focused on secondary level, while six included both primary and secondary teachers. Three studies employed mixed methods, ten were primarily qualitative studies, and five were primarily quantitative.

METHODS

Bronfenbrenner's (The ecology of human development: Experiments by nature and design, Harvard University Press, 1979) framework, adapted by Harvest (How can EPs best support secondary school staff to work effectively with children and young people who experience social, emotional and mental health difficulties? 2018), which includes the mature version of the theory (Tudge et al., 2009, J. Fam. Theory Rev., 1, 198), was used to analyse the literature.

RESULTS

Results found that lack of training in assessment of mental health and 'role conflict' were key barriers; some teachers attributed this to their lack of knowledge, skills and confidence in the area.

CONCLUSION

Implications for practice and research are discussed in relation to the importance of sustained training both pre-service and in-service.

A roadmap to equitable school mental health screening

Youth in the United States are experiencing mental health concerns at alarming rates. Considering the nation's legacy of racism and growing recognition of the impact of social determinants of health on educational and mental health inequities, it is imperative to re-envision how we approach mental health screening in schools to center equity. A focus on mental health screening for the sole purpose of identifying individual at-risk students ignores key contextual considerations, is ineffective in addressing health and educational inequities, and has the potential to perpetuate oppressive practices in schools. Equity-focused mental health screening requires a shift from individual- and deficit-focused approaches to systems- and holistic-focused approaches that (a) identify strengths and stressors among individuals, groups, and communities; (b) dismantle structural forms of oppression; and (c) promote positive mental health outcomes for minoritized youth. Integrating recommendations from the educational equity literature and critical school mental health frameworks, this paper identifies core considerations for equitable school mental health screening and provides guiding principles for each phase of the screening process, from screening readiness to execution to follow up. To implement these recommendations and transform school-based mental health care, schools should (a) incorporate multiple perspectives; (b) prioritize student, family, and community voices; and (c) build collaborative partnerships to co-construct a vision for equitable school mental health.

Early Identification of Social, Emotional, and Behavioral Difficulties by School Staff: A Qualitative Examination of Dutch Primary School Practices

About 16% of Dutch children are reported to have social, emotional, and behavioral difficulties (SEBDs). SEBDs generate distress and pose risks for various negative outcomes; thus, their timely identification is deemed important to respond appropriately to children's needs and avoid such negative outcomes. Primary schools are considered convenient places to implement early SEBD identification, but the ways in which schools achieve this in practice may be inadequate, although the issue remains under-researched. Although there are several systematic school-based early identification methods (e.g., universal or selective screening), primary schools predominantly rely on school staff to recognize children at risk for, or experiencing, SEBDs. As differences in identification practices could impact whether and when (signs of) SEBDs are identified, this study aimed to increase our understanding of differences in identification practices used by school staff and their potential implications for early identification effectiveness. Thirty-four educational and clinical professionals working at nine primary schools participated in in-depth semi-structured interviews. We used MAXQDA to thematically code and analyze the data. Our analysis of these interviews illustrated that schools' identification practices differed on three elements: the frequency of observations, maintaining a four-eyes principle, and the utilization of specialist knowledge. We argue that differences in these elements have potential consequences for the timeliness and quality of SEBD identification.

School-based screening for childhood anxiety problems and intervention delivery: a codesign approach

OBJECTIVES

A very small proportion of children with anxiety problems receive evidence-based treatment. Barriers to access include difficulties with problem identification, concerns about stigma and a lack of clarity about how to access specialist services and their limited availability. A school-based programme that integrates screening to identify those children who are most likely to be experiencing anxiety problems with the offer of intervention has the potential to overcome many of these barriers. This article is a process-based account of how we used codesign to develop a primary school-based screening and intervention programme for child anxiety problems.

DESIGN

Codesign.

SETTING

UK primary schools.

PARTICIPANTS

Data were collected from year 4 children (aged 8-9 years), parents, school staff and mental health practitioners.

RESULTS

We report how the developed programme was experienced and perceived by a range of users, including parents, children, school staff and mental health practitioners, as well as how the programme was adapted following user feedback.

CONCLUSIONS

We reflect on the mitigation techniques we employed, the lessons learnt from the codesign process and give recommendations that may inform the development and implementation of future school-based screening and intervention programmes.

Identifying multilevel and multisectoral strategies to develop a Theory of Change for improving child and adolescent mental health services in a case-study district in South Africa

BACKGROUND

The lack of child and adolescent mental health (CAMH) policies and implementation plans constitute major barriers to CAMH services in low resource settings. Engaging with on-the-ground stakeholders to identify possible contextually appropriate strategies for developing a CAMH collaborative system and inform CAMH plans and policies is important to ensure that resultant policies and plans are feasible and appropriate. Together with key stakeholders across multiple sectors, this study aims to (i) co-identify causal factors and potential strategies to overcome bottlenecks in one district in SA as a case study; and (ii) Co-develop a Theory of Change (ToC) for increasing access to CAMH services within the resource constraints of a remote resource-scarce district as a case study.

METHODS

A participatory workshop was held with key stakeholders (n = 40) from the Departments of Health (DoH), Basic Education (DBE), and Social Development (DSD) and three community-based organisations offering CAMH services in the district. The stakeholders identified context-specific causal factors and possible strategies to address the bottlenecks in the workshop. All the factors identified in the workshop were compared and consolidated. A ToC map was developed based on the data obtained from the workshop. The ToC was further refined by conducting a follow-up virtual workshop with stakeholders (n = 15).

RESULTS

Mapping out the strategies identified in the workshop facilitated the development of a ToC model for the resource-scarce context. Key multilevel and multisectoral task-sharing strategies emerged in support of the development of a collaborative system of care that includes the development of (i) community awareness programs and user-friendly CAMH psychoeducation and screening tools to strengthen mental health literacy and facilitate early identification at the community level; (ii) an intersectoral working group to facilitate intersectoral collaboration (iii) a functional district CAMH referral system, (iv) youth-friendly CAMH care packages.

CONCLUSIONS

In scarce-resource contexts, it is feasible to work collaboratively with key stakeholders across multiple sectors to identify feasible multilevel and multisectoral strategies that can be used to develop a ToC for improved access to CAMH services within a task-sharing approach.

Determining stakeholder priorities and core components for school-based identification of mental health difficulties: A Delphi study

Only approximately half of children and young people (CYP) with mental health difficulties access mental health services in England, with under-identification of need as a contributing factor. Schools may be an ideal setting for identifying mental health difficulties in CYP, but uncertainty remains about the processes by which these needs can best be identified and addressed. In this study, we conducted a two-round, three-panel Delphi study with parents, school staff, mental health practitioners, and researchers to inform the development of a program to identify mental health difficulties in primary schools. We aimed to assess and build consensus regarding (a) the aims of such a program, (b) identification model preferences, (c) key features of the identification model, and (d) key features of the implementation model. A total of 54 and 42 participants completed the Round 1 and 2 questionnaires, respectively. In general, responses indicated that all three panels supported the idea of school-based identification of mental health difficulties. Overall, 53 of a possible 99 items met the criteria for inclusion as program core components. Five main priorities emerged, including that (a) the program should identify children experiencing mental health difficulties across the continuum of severity, as well as children exposed to adversity, who are at greater risk of mental health difficulties; (b) the program should train staff and educate pupils about mental health in parallel; (c) parental consent should be obtained on an opt-out basis; (d) the program must include clear mechanisms for connecting identified pupils to care and support; and (e) to maximize implementation success, the program needs to lie within a school culture that values mental health and wellbeing. In highlighting these priorities, our study provides needed stakeholder consensus to guide further development and evaluation of mental health interventions within schools.

ADHD and ODD Dimensions: Time Varying Prediction of Internalizing Problems from Childhood to Adolescence

OBJECTIVE

Although childhood ADHD is a risk factor for internalizing problems, it consists of separable inattention and hyperactivity dimensions that differentially predict outcomes. Oppositional defiant disorder also consists of separable dimensions (i.e., irritable, oppositional), co-occurs with ADHD, and predicts internalizing outcomes. To discern independent associations with internalizing problems, dimensions must be considered simultaneously.

METHODS

Controlling for age, sex, and race, we tested inattention, hyperactivity, irritability, and oppositionality as time-varying predictors of 6 to 7-year prospective change in parent- and teacher-rated internalizing problems in 230 ethnically- diverse (50% Caucasian) 5 to 10 year old youth (M = 7.4 years, 68% male) with (n = 120) and without ADHD (n = 110).

RESULTS

Escalating inattention and irritability, but not hyperactivity and oppositionality, uniquely predicted internalizing problems.

CONCLUSION

These findings suggest that inattention and irritability are unique risk factors for later internalizing problems. These dimensions may catalyze internalizing problems across development and constitute important intervention targets.

Exploring the Potential of a School-Based Online Health and Wellbeing Screening Tool: Young People's Perspectives

Despite high levels of need, many young people who experience health issues do not seek, access or receive support. Between May and November 2021, using semi-structured interviews, we explored the perspectives of 51 young people (aged 13–14) from two schools who had taken part in a novel online health and wellbeing screening programme, the Digital Health Contact (DHC). One school delivered the DHC during home-learning due to COVID-19 restrictions, whilst the other delivered it in school when restrictions were lifted. The DHC was seen as a useful approach for identifying health need and providing support, and had high levels of acceptability. Young people appreciated the online format of the DHC screening questionnaire and thought this facilitated more honest responses than a face-to-face approach might generate. Completion at home, compared to school-based completion, was perceived as more private and less time-pressured, which young people thought facilitated more honest and detailed responses. Young people’s understanding of the screening process (including professional service involvement and confidentiality) influenced engagement and responses. Overall, our findings afford important insights around young people’s perspectives of participating in screening programmes, and highlight key considerations for the development and delivery of health screening approaches in (and out of) school.

Executive Function in Kindergarten and the Development of Behavior Competence: Moderating Role of Positive Parenting Practices

The present study used data from the Early Childhood Longitudinal Study-Kindergarten Cohort of 2011 (N = 15,827; 51.1% male; 48.4% White, 13.5% Black/African-American, 24.3% Hispanic/Latino, 7.5% Asian, and 6.3% other ethnicity) to examine the unique contribution of specific executive function processes (working memory and cognitive flexibility) at kindergarten entry on externalizing and internalizing behavior problems in spring of kindergarten, after controlling for fall behavior problems and demographic covariates. Due to the transition to elementary school being a critical identification and prevention period, we also focused on examining the moderating role of specific positive parenting practices (i.e., cognitive stimulation, warmth, and behavior management) on associations between child executive function processes and behavioral functioning. Results indicated working memory was negatively associated with parent-reported externalizing and teacher-rated internalizing behavior problems. Further, the association between working memory and parent-rated externalizing problems was moderated by cognitive stimulation, whereas the association between parent-rated internalizing problems was moderated by behavior management. Cognitive flexibility did not have any significant associations. We discuss implications for research and practice on how parenting practices may be leveraged to improve child outcomes.

Under the Surface: The Role of Covert Cues in Peer Suicide Risk Referrals

Suicidal thoughts and behaviors are highly prevalent among adolescents, and peers are often the first, and sometimes only, people to know about youth suicidality. Since many adolescents do not directly disclose suicidal thoughts, school-based suicide prevention programs aim to train youth to recognize warning signs of suicide in their peers that serve as "cues" to refer at-risk peers to an appropriate adult. However, peer-presented cues vary widely in presentation, and adolescents are more likely to recognize overt (i.e., obvious or explicit) as opposed to covert (i.e., hidden or implied) cues. The type of cue exhibited may, in turn, affect whether adolescents make a referral to an adult. The current study examined whether training suicide prevention influences referral intentions for overt and covert suicide cues. Participants included 244 high school students (54% female; M _age = 16.21) in the Southeastern United States who received suicide prevention training (SOS; Signs of Suicide) as part of their health curriculum. Prior to training, students endorsed higher referral intentions for peers exhibiting overt compared to covert cues. Training was associated with increased intentions to refer peers across cue type, but referral intentions for covert cues improved significantly from pre to post-training while those for overt cues remained high and stable. Findings suggest that suicide prevention training might differentially improve students' ability to detect and respond appropriately to less obvious indicators of suicide risk. These findings may inform the adaptation and development of future, more nuanced school-based suicide prevention programming.

Exploring the potential of a school-based online health and wellbeing screening tool: professional stakeholders' perspectives and experiences

Background

Supporting children and young people’s (CYP) mental and physical health is a global policy priority but detecting need and facilitating access to health services and support is challenging. This paper explores professional stakeholders’ perspectives of the acceptability, utility and effectiveness of a school-based online health and wellbeing screening tool, the Digital Health Contact (DHC). The DHC, delivered by Public Health School Nurses (PHSN), aims to identify, and put in place strategies to support, unmet health needs among CYP.

Methods

We employed a qualitative study design, using semi-structured interviews. Fourteen key stakeholders involved in the design and implementation of the DHC (commissioners, providers, PHSN and healthcare staff, school leaders) were purposively sampled. Data were analysed thematically.

Results

Our analysis generated two key themes: the perceived benefits of the DHC; and challenges in delivering the DHC. Stakeholders perceived the universal application of the DHC with linked follow-up intervention as an effective means of identifying and supporting CYP with unmet needs, and an efficient way to target limited service resources. There were barriers around enabling school engagement in the DHC, typically in terms of logistics, school infrastructure, and perspectives of fit with schools. These barriers were seen as being negated through developing effective working relationships between schools and PHSN. Effective relationships could highlight the potential benefits of participation. Overall, the DHC was seen as a valuable and effective use of resources, with a low burden on school staff.

Conclusions

The DHC, as a universal school-based health and wellbeing screening tool with linked follow-up intervention, has great potential in identifying and supporting unmet health needs among CYP. The perspectives and experiences of those involved in delivering the DHC highlight important considerations which may enable effective implementation and delivery of school screening programmes across other areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12748-2.

Developing a Web-Based App to Assess Mental Health Difficulties in Secondary School Pupils: Qualitative User-Centered Design Study

BACKGROUND

Secondary schools are an ideal setting to identify young people experiencing mental health difficulties such as anxiety or depression. However, current methods of identification rely on cumbersome paper-based assessments, which are lengthy and time-consuming to complete and resource-intensive for schools to manage. Artemis-A is a prototype web app that uses computerized adaptive testing technology to shorten the length of the assessment and provides schools with a simple and feasible solution for mental health assessment.

OBJECTIVE

The objectives of this study are to coproduce the main components of the Artemis-A app with stakeholders to enhance the user interface, to carry out usability testing and finalize the interface design and functionality, and to explore the acceptability and feasibility of using Artemis-A in schools.

METHODS

This study involved 2 iterative design feedback cycles-an initial stakeholder consultation to inform the app design and user testing. Using a user-centered design approach, qualitative data were collected through focus groups and interviews with secondary school pupils, parents, school staff, and mental health professionals (N=48). All transcripts were thematically analyzed.

RESULTS

Initial stakeholder consultations provided feedback on preferences for the user interface design, school administration of the assessment, and outcome reporting. The findings informed the second iteration of the app design and development. The unmoderated usability assessment indicated that young people found the app easy to use and visually appealing. However, school staff suggested that additional features should be added to the school administration panel, which would provide them with more flexibility for data visualization. The analysis identified four themes relating to the implementation of the Artemis-A in schools, including the anticipated benefits and drawbacks of the app. Actionable suggestions for designing mental health assessment apps are also provided.

CONCLUSIONS

Artemis-A is a potentially useful tool for secondary schools to assess the mental health of their pupils that requires minimal staff input and training. Future research will evaluate the feasibility and effectiveness of Artemis-A in a range of UK secondary schools.

Benefits of Positive Psychology-Based Story Reading on Adolescent Mental Health and Well-Being

The importance of complete mental health in school context has recently begun to attract a lot of attention. Positive psychology interventions are often associated with improvement in mental health outcomes, but few studies have examined whether story reading is an intervention that is linked with indicators of complete mental health. This study investigated the effects of story reading interventions on both positive and negative indicators of mental health over time for a group of Turkish grade 10 high school students (n = 53). These included 33 students in a story reading group and 20 in a control group for comparison. The results showed that story reading led to improvement in students' mindfulness, optimism, happiness, and positive emotions, and also caused reduction in depression, anxiety, pessimism, and other negative emotions over a 5-week period, with a small to large effect sizes. The obtained results are discussed in the context of their implications for potential psychological interventions in high school settings.

Comparing Informants for Mental Health Screening at the Preschool Level

Universal screening for mental health in preschools provides the opportunity for early identification and early intervention, but guidance regarding which informants to use is needed. Preschoolers' (N = 535) parent and teacher reports across two screening forms were analyzed to determine similarities and discrepancies for classification results and screener scores. The analyses also examined if an additional rater provided incrementally valid information to the prediction of longitudinal kindergarten outcomes. Parents' and teachers' screening scores were significantly correlated across forms by rater and across raters. However, categorical classification results indicated that teachers were more likely than parents to rate preschoolers in at-risk ranges across forms. Finally, hierarchical regression analyses revealed teacher ratings were predictive of kindergarten social-emotional, cognitive, and academic outcomes, and that the addition of parent ratings did not significantly improve prediction of outcomes. Implications are discussed in the context of multiple raters within multiple-gating screening procedures.

Confirmation of a Reconceptualized Definition and Measure of Adolescent Risk Behavior: Adolescent Viewpoints

The goal of this project was to substantiate a more positive conceptualization of adolescent risk behavior and to compare adolescent viewpoints of risk behavior to the items on the Prosocial and Health Adolescent Risk Behavior Scale (PHARBS). A total of 57 high school students participated in the research. Researchers recruited students from an Advanced Placement (AP) Psychology course at a large Midwestern high school. The high school serves approximately 1,750 students in grades 9 through 12. The university Institutional Review Board approved the study procedures. Families provided informed consent, and students assented to participating in one of eight focus group discussions. The focus groups were audio taped, transcribed, and coded. Researchers analyzed the coded data using word count analysis. Students discussed prosocial risk behaviors in addition to health risk behaviors, providing support for the PHARBS and suggesting that adolescents view taking some risks as positive. A more positive conceptualization of risk behavior may better align with how adolescents view risk behavior. Researchers and clinicians might approach adolescent risk behavior measurement and research on the importance of understanding risk behaviors as a normal and potentially positive aspect of adolescent development.

Study protocol: the OxWell school survey investigating social, emotional and behavioural factors associated with mental health and well-being

INTRODUCTION

Improving our understanding of the broad range of social, emotional and behavioural factors that contribute to mental health outcomes in adolescents will be greatly enhanced with diverse, representative population samples. We present a protocol for a repeated self-report survey assessing risk and protective factors for mental health and well-being in school pupils aged 8-18 years with different socioeconomic backgrounds in England. The survey will provide a comprehensive picture of mental health and associated risks at the community level to inform the development of primary and secondary prevention and treatment strategies in schools.

METHODS AND ANALYSIS

This protocol is for a large-scale online repeated self-report survey, representative of children and adolescents aged 8-18 years attending schools or further education colleges in participating counties in England. The survey consists of around 300 questions, including validated measures of mental health and well-being, risk and protective factors, and care-seeking behaviour and preferences. Additional questions each year vary to address current events and novel hypotheses, developed by the research team, collaborators and stakeholders. Primary analyses will investigate current and changing risk and protective factors, care-seeking behaviour and attitudes to allowing linkage of their sensitive data to other databases for research, and will compare measures of mental health to measures of well-being.

ETHICS AND DISSEMINATION

The study was approved by the University of Oxford Research Ethics Committee (Reference: R62366). Tailored data summaries will be provided to participating schools and stakeholders within 3 months of data collection. The main findings will be presented at scientific meetings, published in peer-reviewed journals and shared via digital and social media channels. At the end of the study, other researchers will be able to apply for access to anonymous data extracts.

Impact of counselling provision in primary schools on child and adolescent mental health service referral rates: a longitudinal observational cohort study

BACKGROUND

In the United Kingdom, schools play an increasingly important role in supporting young peoples' mental health. While there is a growing evidence base to support the effectiveness of school-based interventions, less is known about how these provisions impact on local Child and Adolescent Mental Health Service (CAMHS) referral rates. There is a concern that an increase in school-based provision might lead to an increase in CAMHS referrals and overwhelm services. We aimed to examine the longitudinal association between Place2Be counselling provision in primary schools on CAMHS referral rates in South London.

METHOD

This was a retrospective cohort study using linked data from the National Pupil Database (NPD) and CAMHS referrals to the South London and Maudsley's NHS Foundation Trust (SLaM) identified through the Clinical Record Interactive Search (CRIS) tool. The cohort included a total of 285 state-maintained primary schools in four London boroughs for the academic years of 2007-2012. During the study period, 23 of these schools received school-based mental health provision from Place2Be. The primary outcome was the incident rate ratio (IRR) of school-level accepted CAMHS referrals in 2012/13 in schools with, or without, Place2Be provision.

RESULTS

There was no significant association between elevated rates of CAMHS referral and Place2Be provision, even after comprehensive adjustment for school-level and pupil characteristics (IRR 0.91 (0.67-1.23)). School-level characteristics, including higher proportion of white-British pupils (IRR 1.009 (1.002-1.02)), medical staff ratio (IRR 6.49 (2.05-20.6)) and poorer Ofsted school inspection ratings (e.g. IRR 1.58 (1.06-2.34) for 'Requires Improvement' vs. 'Outstanding') were associated with increased CAMHS referral rates.

CONCLUSIONS

Place2Be provision did not result in increased specialist mental health referrals; however, other school-level characteristics did. Future research should investigate pupils' Place2Be clinical outcomes, as well the outcomes of individuals referred to CAMHS to better understand which needs are being met by which services.

Feasibility of School-Based Identification of Children and Adolescents Experiencing, or At-risk of Developing, Mental Health Difficulties: a Systematic Review

Under-identification of mental health difficulties (MHD) in children and young people contributes to the significant unmet need for mental health care. School-based programmes have the potential to improve identification rates. This systematic review aimed to determine the feasibility of various models of school-based identification of MHD. We conducted systematic searches in Medline, Embase, PsycINFO, ERIC, British Education Index, and ASSIA using terms for mental health combined with terms for school-based identification. We included studies that assessed feasibility of school-based identification of students in formal education aged 3-18 with MHD, symptomatology of MHD, or exposed to risks for MHD. Feasibility was defined in terms of (1) intervention fit, (2) cost and resource implications, (3) intervention complexity, flexibility, manualisation, and time concerns, and (4) adverse events. Thirty-three studies met inclusion criteria. The majority focused on behavioural and socioemotional problems or suicide risk, examined universal screening models, and used cross-sectional designs. In general, school-based programmes for identifying MHD aligned with schools' priorities, but their appropriateness for students varied by condition. Time, resource, and cost concerns were the most common barriers to feasibility across models and conditions. The evidence base regarding feasibility is limited, and study heterogeneity prohibits definitive conclusions about the feasibility of different identification models. Education, health, and government agencies must determine how to allocate available resources to make the widespread adoption of school-based identification programmes more feasible. Furthermore, the definition and measurement of feasibility must be standardised to promote any future comparison between models and conditions.

Subtyping of Strengths and Difficulties in a Spanish Children Sample: A Latent Class Analysis

BACKGROUND

Externalizing and internalizing problems are frequent during childhood and are often comorbid. The current study aimed to explore subtypes of strengths and difficulties among Spanish children.

METHODS

The Spanish version of the Strengths and Difficulties Questionnaire was administered to 325 children (47.1% girls), aged 7-12 years (M = 9.64; SD = 1.34). Latent Class Analysis (LCA) was carried out to identify risk profiles in children according to their symptoms. ANOVA and multinomial logistic regression were performed to explore associations between latent classes and SDQ subscales, gender, age and number of siblings.

RESULTS

Five latent classes were found: "high difficulties" (34.2%), "internalizing" (5.2%), "externalizing" (26.5%), "hyperactive" (14.5%), and "well-adjusted" (19.7%). Children belonging to "High difficulties" group showed the highest scores for emotional symptoms, conduct problems, and hyperactivity/inattention. The most prevalent pure profiles were the "externalizing" and "hyperactivity" group, which represent children with elevated behavioral problems, restlessness and distraction. Children in the "internalizing" class showed the highest risk of peer problems.

CONCLUSIONS

These results support the diversity in the patterns of psychological strengths and difficulties and highlight the importance of early detection and intervention, especially in children's behavioral problems, in order to avoid vulnerability to comorbidity and more severe symptoms in the future.

Screening for the at-risk mental state in educational settings: A systematic review

AIM

The at-risk mental state (ARMS) allows clinicians to identify individuals who have an increased risk of developing psychosis. At present, most screening for psychosis-risk is carried out within help-seeking populations; however, screening within educational settings may allow clinicians to identify individuals at-risk earlier and to increase the rate of detection. This review aimed to examine screening for the ARMS in educational settings, with the key questions: what screening tools have been used in educational settings, can screening in educational settings detect individuals with ARMS, what threshold scores in screening tools indicate a positive screen in educational settings, are there comorbid mental health conditions associated with the ARMS in educational settings?

METHODS

Searches were carried out in PsycINFO, MEDLINE, EMBASE, Scopus and Web of Science and reference lists of included articles searched. Results were summarized using narrative synthesis.

RESULTS

Nine papers were included for narrative synthesis. A variety of screening tools have been used when screening for the ARMS in educational settings. The majority of studies have been conducted in schools. The prevalence of the ARMS reported in ranges from 1% to 8%.

CONCLUSIONS

The ARMS indicates the presence of distressing symptoms for which intervention may be beneficial. Screening programmes within educational settings may allow outreach for prodromal symptoms at an earlier stage than clinical settings currently provided for.

Confirmatory Factor Structure and Predictive Validity of the Early Identification System-Student Report in a Community Sample of High School Students

The purpose of this paper is to confirm the factor structure, examine the invariance, and investigate the predictive validity using disciplinary data for 5262 high school students who completed the Early Identification System-Student Response (EIS-SR). The development and theory of the EIS-SR is discussed along with prior work. Building off of prior factor analytic work with a separate sample, it was hypothesized the items of the EIS-SR would coalesce into seven factors representing Externalizing Behavior, Internalizing Behavior, Peer Relationship Problems, School Disengagement, Emotional Dysregulation, Attention and Academic Issues, and Relational Aggression. Furthermore, it was hypothesized that EIS-SR scores would be invariant with regard to gender and grade level. Lastly, it was hypothesized that students with high EIS-SR subscale scores would be predictive of school discipline events. Our analyses indicated the EIS-SR did fit the previously observed factor structure with the items loading on seven distinct scales. Tests for measurement invariance indicated support that the EIS-SR measured the seven factors equally well regardless of both gender and grade level. Lastly, EIS-SR subscale scores predicted spring office disciplinary referrals, both in and out of school suspensions, and attendance.

Prevalence of mental health problems in Chinese schoolchildren: The influence of measuring impact score and combining information from multiple informants

BACKGROUND

To measure the effects of using different combinations of multiple informants and the impact score on the estimated prevalence of mental health problems in Chinese schoolchildren.

METHODS

Complete information on the Strengths and Difficulties Questionnaire (SDQ) were obtained from students (S), parents (P), and teachers (T) for 4986 schoolchildren (11-17 years-old). We used 3 criteria to determine the prevalence of mental health problems: SDQ cut-off value (previously established in the United Kingdom), SDQ cut-off value plus an impact score of 1 or more, or plus an impact score of 2 or more. A student was defined as having a mental health problem if any informant (S, P, or T) classified the child as 'abnormal'. We compared the prevalence of mental health problems determined from 1 informant, 2 informants, and 3 informants.

RESULTS

The prevalence of overall mental health problems increased with rising number of informants, but decreased with increasing impact score. When the impact score was not considered, the prevalence was 8.2% to 14.2% when rated by 1 informant, 18.8% to 24.7% when rated by 2 informants, and 28.3% when rated by all 3 informants. Failure to measure the impact score led to a two to threefold greater estimate of the prevalence of mental health problems.

CONCLUSIONS

The types, number, and combinations of multiple informants and use of the impact score must be considered when comparing the results of different studies. It is preferable to use multiple informants and have the impact score taken the impact into account to reflect the real burden of mental health burden in children and adolescent.

Academic achievement and schizophrenia: a systematic meta-analysis

BACKGROUND

Cognitive impairments in childhood are associated with increased risk of schizophrenia in later life, but the extent to which poor academic achievement is associated with the disorder is unclear.

METHODS

Major databases were searched for articles published in English up to 31 December 2019. We conducted random-effects meta-analyses to: (1) compare general academic and mathematics achievement in youth who later developed schizophrenia and those who did not; (2) to examine the association between education level achieved and adult-onset schizophrenia; and, (3) compare general academic achievement in youth at-risk for schizophrenia and typically developing peers. Meta-regression models examined the effects of type of academic assessment, educational system, age at assessment, measurement of educational level attained, school leaving age, and study quality on academic achievement and education level among individuals with schizophrenia.

RESULTS

Meta-analyses, comprising data of over four million individuals, found that: (1) by age 16 years, those who later developed schizophrenia had poorer general academic (Cohen's d = -0.29, p ⩽ 0.0001) and mathematics achievement (d = -0.23, p = 0.01) than those who did not; (2) individuals with schizophrenia were less likely to enter higher education (odds ratio = 0.49, p ⩽ 0.0001); and, (3) youth reporting psychotic-like experiences and youth with a family history of schizophrenia had lower general academic achievement (d = -0.54, p ⩽ 0.0001; d = -0.39, p ⩽ 0.0001, respectively). Meta-regression analyses determined no effect modifiers.

DISCUSSION

Despite significant heterogeneity across studies, various routinely collected indices of academic achievement can identify premorbid cognitive dysfunction among individuals who are vulnerable for schizophrenia, potentially aiding the early identification of risk in the population.

Development and Preliminary Validation of the University of Minnesota's Traumatic Stress Screen for Children and Adolescents (TSSCA)

Child and adolescent exposure to potential trauma experiences is pervasive. Given the prevalence, deleterious mental and physical effects, and economic cost of trauma exposure, child- and family-service systems are adopting trauma-informed approaches, including practices like trauma screening. Although a number of trauma-focused screening and assessment measures exist for youth, the majority are lengthy and inappropriate for universal administration. This study describes the development and preliminary validation of the Traumatic Stress Screen for Children and Adolescents (TSSCA), a six-item screening measure for trauma exposure and traumatic stress symptoms. Using two samples of youth presenting at community practice settings (n₁ = 134, n₂ = 137), reliability, discriminative validity, and criterion-related validity were calculated for the TSSCA. Results support the TSSCA as an empirically derived, reliable, and valid screening measure for exposure to trauma and symptoms of traumatic stress for youth ages 7 to 18.

The Hummingbird Project: A Positive Psychology Intervention for Secondary School Students

Mental health in schools has attracted a lot of attention in recent years. Positive Psychology Interventions (PPIs) in secondary schools have been shown to improve mental health outcomes for students. Previous PPIs have tended to be delivered by trained Psychology specialists or have tended to focus on a single aspect of Positive Psychology such as Mindfulness. The current study involved 2 phases. Phase 1 was a pilot PPI, delivered by current university students in Psychology, which educated secondary school students (N = 90) in a variety of Positive Psychology concepts. Phase 2 involved delivering the PPI to secondary school students (N = 1,054). This PPI, the Hummingbird Project, led to improvements in student well-being, as measured by the World Health Organization Well-Being Index (WHO-5). The intervention also led to improvements in student resilience, as measured by the Bolton Uni-Stride Scale (BUSS), and hope, as measured by the Children's Hope Scale (CHS). Results are discussed in the context of their implications for the future of psychological intervention in secondary school settings.

Exploring the Alignment of Behavior Screening Policies and Practices in US Public School Districts

BACKGROUND

Although recent studies provide information regarding state-level policies and district-level practices regarding social, emotional, and behavioral screening, the degree to which these policies influence screening practices is unknown. As such, the purpose of this exploratory study was to compare state- and district-level policies and reported practices around school-based social, emotional, and behavioral screening.

METHODS

We obtained data for the present study from three sources: (1) a recent systematic review of state department of education websites; (2) a national survey of 1330 US school districts; and (3) a Web search and review of policy manuals published by the 1330 school districts. Comparative analyses were used to identify similarities and differences across state and district policies and practices.

RESULTS

Of the 1330 districts searched, 911 had policy manuals available for review; 87 of these policy manuals, which represented 10 states, met inclusion criteria, and thus, were included in analyses. Discrepancies were found across state and district policies and across state social, emotional, and behavioral screening guidance and district practices, but consistencies did exist across district policies within the same state.

CONCLUSION

District-level guidance around social, emotional, and behavioral screening appears to be limited. Our findings suggest a disconnect between state- and district-level social, emotional, and behavioral screening guidance and district reported practices, which signifies the need to identify the main influences on district- and school-level screening practices.

Psychosis screening in schools: Considerations and implementation strategies

AIM

Duration of untreated psychosis, or the time between onset of psychosis symptoms and accurate diagnosis and treatment, is a significant predictor of both initial treatment response and long-term outcomes. As such, efforts to improve rapid identification are key. Because early signs of psychosis commonly emerge in adolescence, schools have the potential to play an important role in the identification of psychosis-spectrum disorders.

METHODS

To illustrate the potential role of schools in this effort, the current paper describes implementation of a psychosis screening tool as part of a larger study focused on reducing the duration of untreated psychosis in Sacramento, CA.

RESULTS

Clinical considerations related to screening for psychosis in schools, including ethical concerns, logistics, screening population and stigma are addressed. Implementation strategies to address these concerns are suggested.

CONCLUSIONS

Early psychosis screening in the school system could improve early identification, reduce stigma and may represent an important further step towards an integrative system of mental health.

Pediatric Symptom Checklist-17

Abstract. The Pediatric Symptom Checklist-17 (PSC-17) is a screener designed to measure children’s behavioral and emotional problems. The measurement invariance of the scale’s higher-order factor structure was investigated in the current study. Gender invariance was established through a series of tests for configural invariance (baseline model), metric invariance, scalar invariance, residual variance invariance of items, higher-order factor loadings invariance, intercepts invariance of first-order factors, disturbances invariance of first-order factors, and factor variance invariance of a higher-order factor. The latent mean difference of the higher-order factor indicates that boys exhibited more problems with a strong effect size ( d = .870). As invariance holds, the PSC-17 may be an option to identify preschool children’s behavioral and emotional problems in Response to Intervention programs in school-based settings.