The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial

Estimating the Lifetime Costs and Benefits of the Incredible Years Teacher Classroom Management Intervention Using Data From 30 Months Follow-Up of the Supporting Teachers and childRen in Schools Trial

OBJECTIVES

The Incredible Years Teacher® Classroom Management (IY-TCM) intervention is associated with short-term improvements in mental health difficulties in young people. The aim was to estimate the long-term impact and cost-effectiveness of the IY-TCM intervention compared with no intervention.

METHODS

An existing health economic model (LifeSim 1.0) was used to translate short-term changes in the Strength and Difficulties Questionnaire (SDQ), based on the Supporting Teachers and childRen in Schools cluster randomized controlled trial of the IY-TCM intervention in schools, into estimated medium- and long-term effects using multiple longitudinal data sets. LifeSim 1.0 was adapted to incorporate teacher-reported SDQ and account for individual heterogeneity. Cost-effectiveness analyses were conducted using the trial-based intervention cost with subgroup analyses on deprivation, conduct scores and parental depression in the simulated baseline population.

RESULTS

Regression analyses show significant predictor variables for intervention effectiveness, including deprivation and baseline SDQ. LifeSim results indicate small gains in long-term outcomes, and cost-effective analyses estimated that the IY-TCM intervention could be cost-effective, but there was a large amount of uncertainty (net monetary benefit = £10, Estimated CI = -£134, £156). Benefits and certainty of cost-effectiveness were greater for some subgroups, such as those with high conduct scores at baseline (net monetary benefit = £206, Estimated CI = £26, £318).

CONCLUSIONS

IY-TCM could be cost-effective, but there was a large amount of uncertainty around costs and benefits. Greater benefits for pupils with difficulties at baseline suggest that the intervention may be more cost-effective for schools in more deprived areas with high levels of conduct problems.

Is neighbourhood deprivation in primary school-aged children associated with their mental health and does this association change over 30 months?

As both socioeconomic deprivation and the prevalence of childhood mental health difficulties continue to increase, exploring the relationship between them is important to guide policy. We aimed to replicate the finding of a mental health gap that widened with age between those living in the most and least deprived areas among primary school pupils. We used data from 2075 children aged 4-9 years in the South West of England recruited to the STARS (Supporting Teachers and childRen in Schools) trial, which collected teacher- and parent-reported Strength and Difficulties Questionnaire (SDQ) at baseline, 18-month and 30-month follow-up. We fitted multilevel regression models to explore the relationship between Index of Multiple Deprivation (IMD) quintile and SDQ total difficulties score and an algorithm-generated "probable disorder" variable that combined SDQ data from teachers and parents. Teacher- and parent-reported SDQ total difficulties scores indicated worse mental health in children living in more deprived neighbourhoods, which was attenuated by controlling for special educational needs and disabilities but remained significant by parent report, and there was no interaction year group status (age) at baseline. We did not detect an association between probable disorder and IMD although an interaction with time was evident (p = 0.003). Analysis by study wave revealed associations at baseline (odds ratio 1.94, 95% confidence interval 0.97-3.89) and 18 months (1.96, 1.07-3.59) but not 30 months (0.94, 0.54-1.57). These findings augment the existing, highly compelling evidence demonstrating worse mental health in children exposed to socioeconomic deprivation.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a disruptive behaviour disorder involving an ongoing pattern of angry/irritable mood, argumentative/defiant behaviour and vindictiveness. Onset is typically before 8 years of age, although ODD can be diagnosed in both children and adults. This disorder is associated with substantial social and economic burden, and childhood ODD is one of the most common precursors of other mental health problems that can arise across the lifespan. The population prevalence of ODD is ~3 to 5%. A higher prevalence in males than females has been reported, particularly before adolescence. No single risk factor accounts for ODD. The development of this disorder seems to arise from the interaction of genetic and environmental factors, and mechanisms embedded in social relationships are understood to contribute to its maintenance. The treatment of ODD is often successful, and relatively brief parenting interventions produce large sized treatment effects in early childhood. Accordingly, ODD represents an important focus for research, practice and policy concerning early intervention and prevention in mental health.

Investigation of the feasibility and acceptability of a school-based intervention for children with traits of ADHD: protocol for an iterative case-series study

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) is a prevalent and impairing cluster of traits affecting 2%-5% of children. These children are at risk of negative health, social and educational outcomes and often experience severe difficulties at school, so effective psychosocial interventions are needed. There is mixed evidence for existing school-based interventions for ADHD, which are complex and resource-intensive, contradicting teachers' preferences for short, flexible strategies that suit a range of ADHD-related classroom-based problems. They are also poorly evaluated. In this study, a prototype intervention comprising a digital 'toolkit' of behavioural strategies will be tested and refined. We aim to refine the prototype so that its use is feasible and acceptable within school settings, and to establish whether a future definitive, appropriately powered, trial of effectiveness is feasible. This novel iterative study aims to pre-emptively address implementation and evaluation challenges that have hampered previous randomised controlled trials of non-pharmacological interventions.

METHODS AND ANALYSIS

A randomised iterative mixed-methods case-series design will be used. Schools will be randomised to the time (school term) they implement the toolkit. Eight primary schools and 16-32 children with impairing traits of ADHD will participate, along with school staff and parents. The toolkit will be refined after each term, or more frequently if needed. Small, theory-based and data driven changes hypothesised as relevant across school contexts will be made, as well as reactive changes addressing implementation barriers. Feasibility and acceptability will be assessed through quantitative and qualitative data collection and analyses in relation to study continuation criteria, and ADHD symptoms and classroom functioning will be tracked and visually evaluated to assess whether there are early indications of toolkit utility.

ETHICS AND DISSEMINATION

Ethical approval has been obtained. Results will be presented in journal articles, conferences and through varied forms of media to reach policymakers, stakeholders and the public.

Minimising Young Children's Anxiety through Schools (MY-CATS): statistical analysis plan for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

The Minimising Young Children's Anxiety through Schools (MY-CATS) trial is being conducted to determine whether an online evidence-based parent-guided cognitive behavioural therapy intervention in addition to usual school practice is effective and cost-effective compared with usual school practice in reducing anxiety disorders in children aged 4-7 deemed 'at risk' of anxiety disorders. This update article describes the detailed statistical analysis plan for the MY-CATS trial and reports a review of the underpinning sample size assumptions.

METHODS AND DESIGN

The MY-CATS study is a two-arm, definitive superiority pragmatic parallel group cluster randomised controlled trial in which schools will be randomised 1:1 to receive either the intervention (in addition to usual school practice) or the usual school practice only. This update to the (published) protocol provides a detailed description of the study methods, the statistical principles, the trial population and the planned statistical analyses, including additional analyses comprising instrumental variable regression and mediation analysis.

TRIAL REGISTRATION

ISRCTN82398107 . Prospectively registered on 14 January 2021.

Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i): protocol for a cluster randomised controlled trial to compare screening, feedback and intervention for child anxiety problems to usual school practice

Background

Systematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for (1) children (aged 8–9) who screen positive for anxiety problems at baseline (target population) and (2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice (‘screening and intervention’), compared to assessment and usual school practice only (‘usual school practice’). 

Methods

The trial design is a parallel-group, superiority cluster randomised controlled trial, with schools (clusters) randomised to ‘screening and intervention’ or ‘usual school practice’ arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to ‘screening and intervention’: (1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child’s screening outcomes (after randomisation), (2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention and (3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent- and teacher-report measures for the target population and total population at baseline (before randomisation), 4 months, 12 months and 24 months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12 months post-randomisation.

Discussion

This trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families and delivering a brief parent-led online intervention through schools is effective and cost-effective.

Trial registration

ISRCTN registry ISRCTN76119074. Prospectively registered on 4.1.2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06773-0.

Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i): protocol for single-arm feasibility trial

Background

Anxiety disorders are common among primary-school aged children, but few affected children receive evidence-based treatment. Identifying and supporting children who experience anxiety problems through schools would address substantial treatment access barriers that families and school staff often face. We have worked with families and school staff to co-design procedures that incorporate screening, feedback for parents, and the offer of a brief intervention in primary schools. This study sets out to assess the feasibility of a subsequent school-based cluster randomised controlled trial to evaluate these procedures. Our objectives are to ensure our procedures for identifying and supporting children with anxiety difficulties through primary schools are acceptable and there are no negative impacts, to estimate recruitment and retention rates, and to identify any changes needed to study procedures or measures.

Methods

We will recruit six primary/junior schools in England (2 classes per school), and invite all children (aged 8–9) (n = 360) and their parent/carer and class teacher in participating classes to take part. Children, parents and class teachers will complete questionnaires at baseline and 12-week follow-up. Children who ‘screen positive’ on a 2-item parent-report child anxiety screen at baseline will be the target population (expected n = 43). Parents receive feedback on screening questionnaire responses, and where the child screens positive the family is offered support (OSI: Online Support and Intervention for child anxiety). OSI is a brief, parent-led online intervention, supported by short telephone sessions with a Children’s Wellbeing Practitioner. Participants’ experiences of study procedures will be assessed through qualitative interviews/discussion groups.

Discussion

Evidence-based procedures for identifying and supporting children with anxiety difficulties through primary schools would improve children’s access to timely, effective intervention for anxiety difficulties.

Trial registration

ISRCTN registry: ISRCTN30032471. Retrospectively registered on 18 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01140-x.

The Good Behaviour Game intervention to improve behavioural and other outcomes for children aged 7–8 years: a cluster RCT

Background

Universal, school-based behaviour management interventions can produce meaningful improvements in children’s behaviour and other outcomes. However, the UK evidence base for these remains limited.

Objective

The objective of this trial was to investigate the impact, value for money and longer-term outcomes of the Good Behaviour Game. Study hypotheses centred on immediate impact (hypothesis 1); subgroup effects (at-risk boys, hypothesis 2); implementation effects (dosage, hypothesis 3); maintenance/sleeper effects (12- and 24-month post-intervention follow-ups, hypothesis 4); the temporal association between mental health and academic attainment (hypothesis 5); and the health economic impact of the Good Behaviour Game (hypothesis 6).

Design

This was a two-group, parallel, cluster-randomised controlled trial. Primary schools (n = 77) were randomly assigned to implement the Good Behaviour Game for 2 years or continue their usual practice, after which there was a 2-year follow-up period.

Setting

The trial was set in primary schools across 23 local authorities in England.

Participants

Participants were children (n = 3084) aged 7–8 years attending participating schools.

Intervention

The Good Behaviour Game is a universal behaviour management intervention. Its core components are classroom rules, team membership, monitoring behaviour and positive reinforcement. It is played alongside a normal classroom activity for a set time, during which children work in teams to win the game to access the agreed rewards. The Good Behaviour Game is a manualised intervention delivered by teachers who receive initial training and ongoing coaching.

Main outcome measures

The measures were conduct problems (primary outcome; teacher-rated Strengths and Difficulties Questionnaire scores); emotional symptoms (teacher-rated Strengths and Difficulties Questionnaire scores); psychological well-being, peer and social support, bullying (i.e. social acceptance) and school environment (self-report Kidscreen survey results); and school absence and exclusion from school (measured using National Pupil Database records). Measures of academic attainment (reading, standardised tests), disruptive behaviour, concentration problems and prosocial behaviour (Teacher Observation of Child Adaptation Checklist scores) were also collected during the 2-year follow-up period.

Results

There was no evidence that the Good Behaviour Game improved any outcomes (hypothesis 1). The only significant subgroup moderator effect identified was contrary to expectations: at-risk boys in Good Behaviour Game schools reported higher rates of bullying (hypothesis 2). The moderating effect of the amount of time spent playing the Good Behaviour Game was unclear; in the context of both moderate (≥ 1030 minutes over 2 years) and high (≥ 1348 minutes over 2 years) intervention compliance, there were significant reductions in children’s psychological well-being, but also significant reductions in their school absence (hypothesis 3). The only medium-term intervention effect was for peer and social support at 24 months, but this was in a negative direction (hypothesis 4). After disaggregating within- and between-individual effects, we found no temporal within-individual associations between children’s mental health and their academic attainment (hypothesis 5). Last, our cost–consequences analysis indicated that the Good Behaviour Game does not provide value for money (hypothesis 6).

Limitations

Limitations included the post-test-only design for several secondary outcomes; suboptimal implementation dosage (mitigated by complier-average causal effect estimation); and moderate child-level attrition (18.5% for the primary outcome analysis), particularly in the post-trial follow-up period (mitigated by the use of full information maximum likelihood procedures).

Future work

Questions remain regarding programme differentiation (e.g. how distinct is the Good Behaviour Game from existing behaviour management practices, and does this makes a difference in terms of its impact?) and if the Good Behaviour Game is impactful when combined with a complementary preventative intervention (as has been the case in several earlier trials).

Conclusion

The Good Behaviour Game cannot be recommended based on the findings reported here.

Trial registration

This trial is registered as ISRCTN64152096.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

School educational models and child mental health among K-12 students: a scoping review

BACKGROUND

The promotion of mental health among children and adolescents is a public health imperative worldwide, and schools have been proposed as the primary and targeted settings for mental health promotion for students in grades K-12. This review sought to provide a comprehensive understanding of key factors involved in models of school education contributing to student mental health development, interrelationships among these factors and the cross-cultural differences across nations and societies.

METHODS

This scoping review followed the framework of Arksey and O'Malley and holistically reviewed the current evidence on the potential impacts of school-related factors or school-based interventions on student mental health in recent 5 years based on the PubMed, Web of Science, Embase and PsycExtra databases.

RESULTS/FINDINGS

After screening 558 full-texts, this review contained a total of 197 original articles on school education and student mental health. Based on the five key factors (including curriculum, homework and tests, physical activities, interpersonal relationships and after-school activities) identified in student mental development according to thematic analyses, a multi-component school educational model integrating academic, social and physical factors was proposed so as to conceptualize the five school-based dimensions for K-12 students to promote student mental health development.

CONCLUSIONS

The lessons learned from previous studies indicate that developing multi-component school strategies to promote student mental health remains a major challenge. This review may help establish appropriate school educational models and call for a greater emphasis on advancement of student mental health in the K-12 school context among different nations or societies.

What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review

Mental health (MH) difficulties are on the increase among children and young people (CYP). Evidence has shown that educational settings contain both risk and protective factors for MH. This review investigated which structural and cultural factors and interventions within educational settings promote positive MH and prevent poor MH in 4–18 year olds. Searches were conducted in PsychINFO, Embase, ERIC, ASSIA and British Education Index, and reference lists from key studies and relevant systematic reviews were hand-searched. Intervention, cohort, and qualitative studies were included. Of the 62 included papers, 36 examined cultural factors (30 social/relational and six value-related) while 12 studies examined structural factors (eight organisational and four physical) and 14 studies examined multiple factors. There was strong evidence for the impact of positive classroom management techniques, access to physical activity, and peer mentoring on student MH. Studies examining the impact of positive school culture, teacher training in MH and parent involvement in school MH activities also found predominantly positive results for student MH, albeit the evidence was of lower quality or from a low number of studies. Few studies explicitly examined the impact of interventions on MH inequalities; those that did indicated limited if any reduction to inequalities. A very small number of studies suggested that interventions targeting those at risk of poor MH due to socioeconomic factors could successfully improve wellbeing and reduce depression, anxiety and behavioural problems. Studies exploring the effect of management and leadership strategies within schools, policies, and aspects of the physical environment other than green space were scarce or absent in the literature. This review highlights the need to consider the ways in which educational settings are organised, the culture that is created and the physical space in order to improve the MH of CYP.

Teachers' views on the acceptability and implementation of the Incredible Years® Teacher Classroom Management programme in English (UK) primary schools from the STARS trial

Background

The Incredible Years^® (IY) Teacher Classroom Management (TCM) programme may reduce disruptive behaviour in the classroom and improve child and teacher mental health; however, few studies have considered how acceptable TCM is to teachers or what facilitators and barriers there are to its implementation.

Aims

In this paper we examine the acceptability of the full 6‐day TCM programme and teachers’ perceived barriers and facilitators to implementation in the English (UK) primary school context.

Sample

Forty‐four English (UK) primary school teachers who attended the TCM programme as part of the STARS trial.

Methods

We completed focus groups and telephone interviews with participating teachers 2 months after they completed the TCM programme. Thematic analysis was used to examine the data, and a framework approach was applied to organize and summarize themes.

Results

Teachers liked the structure of the course, the peer group learning environment, delivery methods, and the opportunity to reflect outside the classroom on their practice. They reported that the video clips used lacked cultural relevance and highlighted the importance of group leadership style. Perceived facilitators to implementation included an understanding of the theory underpinning TCM and adaptability of the TCM strategies. Barriers included perceived gaps in the course content in relation to challenging behaviour, applying strategies with older children and the school context within which teachers were working.

Conclusion

Our findings suggest high levels of acceptability to TCM overall, but also highlight the need for a whole school approach to combat potential barriers to implementation.

Minimising young children's anxiety through schools (MY-CATS): protocol for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.

METHODS

The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.

DISCUSSION

The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.

TRIAL REGISTRATION

ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021.

A Meta-Analysis of the Current State of Evidence of the Incredible Years Teacher-Classroom Management Program

This meta-analysis evaluated the current state of evidence and identified potential treatment moderators of the Incredible Years Teacher Classroom Management (IYTCM) program used to reduce externalizing and internalizing behaviors in school-aged children. Inclusion criteria involved published studies between 1984–2018 and examining the effects of IYTCM as a standalone program on teacher and/or child behavioral outcomes. We identified and narratively summarized potential moderators, which included the severity of child behavior, dosage, study design, and reporting methods. Overall, effect sizes revealed IYTCM had moderate positive effects on teachers and small positive effects on children. Narrative summaries indicated larger effect sizes in higher dosage studies and higher risk children. The results align with previous systematic reviews on the Incredible Years Parent Training (IYPT) program but this is the first study to look at the teacher training program. Overall, IYTCM seems to be an effective intervention; however, what components of this program work best, for whom, and under what conditions require further empirical investigation.

Mental health support and training to improve secondary school teachers’ well-being: the WISE cluster RCT

Background

Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves.

Objective

To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training.

Design

A cluster randomised controlled trial with embedded process and economic evaluations.

Setting

Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016.

Participants

All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up).

Intervention

Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice.

Main outcome measures

The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models.

Economic evaluation

A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis.

Process evaluation

A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context.

Results

All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture.

Limitations

Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage.

Conclusions

The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life.

Future work

Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions.

Trial registration

Current Controlled Trials ISRCTN95909211.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

An intervention to improve teacher well-being support and training to support students in UK high schools (the WISE study): A cluster randomised controlled trial

BACKGROUND

Teachers are at heightened risk of poor mental health and well-being, which is likely to impact on the support they provide to students, and student outcomes. We conducted a cluster randomised controlled trial, to test whether an intervention to improve mental health support and training for high school teachers led to improved mental health and well-being for teachers and students, compared to usual practice. We also conducted a cost evaluation of the intervention.

METHODS AND FINDINGS

The intervention comprised (i) Mental Health First Aid training for teachers to support students; (ii) a mental health awareness session; and (iii) a confidential staff peer support service. In total 25 mainstream, non-fee-paying secondary schools stratified by geographical area and free school meal entitlement were randomly allocated to intervention (n = 12) or control group (n = 13) after collection of baseline measures. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience. The primary outcome was teacher well-being (Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student well-being, mental health difficulties, attendance, and attainment. Follow-up was at months 12 (T1) and 24 (T2). We collected process data to test the logic model underpinning the intervention, to aid interpretation of the findings. A total of 1,722 teachers were included in the primary analysis. Teacher well-being did not differ between groups at T2 (intervention mean well-being score 47.5, control group mean well-being score 48.4, adjusted mean difference -0.90, 95% CI -2.07 to 0.27, p = 0.130). The only effect on secondary outcomes was higher teacher-reported absence among the intervention group at T2 (intervention group median number of days absent 0, control group median number of days absent 0, ratio of geometric means 1.04, 95% CI 1.00 to 1.09, p = 0.042). Process measures indicated little change in perceived mental health support, quality of relationships, and work-related stress. The average cost of the intervention was £9,103 per school. The study's main limitations were a lack of blinding of research participants and the self-report nature of the outcome measures.

CONCLUSIONS

In this study, we observed no improvements to teacher or student mental health following the intervention, possibly due to a lack of impact on key drivers of poor mental health within the school environment. Future research should focus on structural and cultural changes to the school environment, which may be more effective at improving teacher and student mental health and well-being.

TRIAL REGISTRATION

www.isrctn.com ISRCTN95909211.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the United Kingdom: a methodological systematic review

Background

Cluster randomised trials (CRTs) are increasingly used to evaluate non-pharmacological interventions for improving child health. Although methodological challenges of CRTs are well documented, the characteristics of school-based CRTs with pupil health outcomes have not been systematically described. Our objective was to describe methodological characteristics of these studies in the United Kingdom (UK).

Methods

MEDLINE was systematically searched from inception to 30^th June 2020. Included studies used the CRT design in schools and measured primary outcomes on pupils. Study characteristics were described using descriptive statistics.

Results

Of 3138 articles identified, 64 were included. CRTs with pupil health outcomes have been increasingly used in the UK school setting since the earliest included paper was published in 1993; 37 (58%) studies were published after 2010. Of the 44 studies that reported information, 93% included state-funded schools. Thirty six (56%) were exclusively in primary schools and 24 (38%) exclusively in secondary schools. Schools were randomised in 56 studies, classrooms in 6 studies, and year groups in 2 studies. Eighty percent of studies used restricted randomisation to balance cluster-level characteristics between trial arms, but few provided justification for their choice of balancing factors. Interventions covered 11 different health areas; 53 (83%) included components that were necessarily administered to entire clusters. The median (interquartile range) number of clusters and pupils recruited was 31.5 (21 to 50) and 1308 (604 to 3201), respectively. In half the studies, at least one cluster dropped out. Only 26 (41%) studies reported the intra-cluster correlation coefficient (ICC) of the primary outcome from the analysis; this was often markedly different to the assumed ICC in the sample size calculation. The median (range) ICC for school clusters was 0.028 (0.0005 to 0.21).

Conclusions

The increasing pool of school-based CRTs examining pupil health outcomes provides methodological knowledge and highlights design challenges. Data from these studies should be used to identify the best school-level characteristics for balancing the randomisation. Better information on the ICC of pupil health outcomes is required to aid the planning of future CRTs. Improved reporting of the recruitment process will help to identify barriers to obtaining representative samples of schools.

Causal inference with observational data: the need for triangulation of evidence

The goal of much observational research is to identify risk factors that have a causal effect on health and social outcomes. However, observational data are subject to biases from confounding, selection and measurement, which can result in an underestimate or overestimate of the effect of interest. Various advanced statistical approaches exist that offer certain advantages in terms of addressing these potential biases. However, although these statistical approaches have different underlying statistical assumptions, in practice they cannot always completely remove key sources of bias; therefore, using design-based approaches to improve causal inference is also important. Here it is the design of the study that addresses the problem of potential bias - either by ensuring it is not present (under certain assumptions) or by comparing results across methods with different sources and direction of potential bias. The distinction between statistical and design-based approaches is not an absolute one, but it provides a framework for triangulation - the thoughtful application of multiple approaches (e.g. statistical and design based), each with their own strengths and weaknesses, and in particular sources and directions of bias. It is unlikely that any single method can provide a definite answer to a causal question, but the triangulation of evidence provided by different approaches can provide a stronger basis for causal inference. Triangulation can be considered part of wider efforts to improve the transparency and robustness of scientific research, and the wider scientific infrastructure and system of incentives.

Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial

Background

Evidence suggests that dietary intake of UK children is suboptimal. As schools provide an ideal natural environment for public health interventions, effective and sustainable methods of improving food knowledge and dietary habits in this population must be identified. Project Daire aimed to improve children’s health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions.

Methods

Daire was a randomised-controlled, factorial design trial evaluating two interventions across four arms. Primary schools in Northern Ireland were randomised to one of four 6-month intervention arms: i) ‘Nourish’, ii) ‘Engage’, iii) ‘Nourish’ and ‘Engage’ and iv) Control (Delayed). ‘Nourish’ was an intervention aiming to alter the whole-school food environment, provide food-related experiences and exposure to locally produced foods. ‘Engage’ was an age-appropriate, cross-curricular educational intervention on food, agriculture, nutrition science and related careers. Primary outcomes were emotional and behavioural wellbeing and health-related quality of life. A number of secondary outcomes, including dietary intake, cooking competence and food-related knowledge, were also measured.

Results

Fifteen schools from areas of varying socio-economic status participated in the randomised trial. A total of 903 (n = 445 aged 6–7 years and n = 458 aged 10–11 years) primary school pupils took part. Total Difficulties Score improved in all pupils (6–7 and 10–11 year old pupils) who received the ‘Nourish’ intervention compared with those that did not (adjusted difference in mean = − 0.82; 95% CI -1.46, − 0.17; P < 0.02). No statistically significant difference in Health-Related Quality of Life was observed. The ‘Nourish’ intervention also produced some changes in school-based dietary behaviour, which were most apparent in the 10–11 year old pupils. The ‘Nourish’ intervention also produced improvements in understanding of food labels (adjusted difference in mean = 0.15; 95% CI 0.05, 0.25; P < 0.01) and knowledge of vegetables in season (adjusted difference in mean = 0.29; 95% CI 0.01,0.56; P = 0.04) whilst an increased willingness to try new foods and improved perceived cooking competence was also observed.

Conclusions

Improvements in childhood emotional and behavioural wellbeing, dietary intake, knowledge about food, cooking skills and willingness to try new foods were associated with the ‘Nourish’ whole-school food environment intervention. Exploration of the sustainability and long-term effectiveness of such whole-school food interventions should be conducted.

Trial registration

National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01086-y.

Attainment, attendance, and school difficulties in UK primary schoolchildren with probable ADHD

BACKGROUND

Among children aged 6-16, there is a clear association between attention-deficit/hyperactivity disorder (ADHD) symptoms and academic attainment. We wanted to know whether this association was replicated in younger children.

AIMS

To explore the relationship between children aged 4-8 with probable ADHD and their academic attainment and school attendance. Secondly, the study aimed to explore their behaviour within school and their reported attitudes towards school.

SAMPLE

A total of 1,152 children who were taking part in the Supporting Teachers and Children in Schools (STARS) cluster randomized controlled trial.

METHODS

ADHD status was established by using the Strengths and Difficulties Questionnaire predictive algorithm to identify children with probable ADHD. Using baseline data, random-effects regression models on ADHD status were fitted to attainment, attendance, special educational needs (SEN) provision, and attitudes towards school and classroom behaviour; models that were also fitted to attainment were evaluated again at 9, 18, and 30 months after baseline.

RESULTS

Children with probable ADHD (n = 47) were more likely than controls (n = 1,105) to have below-expected attainment in literacy (odds ratio (OR) 16.7, 95% CI 6.93-to-40.1), numeracy (OR 11.3, 95% CI 5.34-to-24.1) and to be identified as having SEN (OR-55.2, 95%-CI 22.1-to-137). Their attendance was poorer with more unauthorized absences (rate ratio (RR)-1.91, 95%-CI-1.57-to-2.31). They had more teacher-reported behavioural problems (mean difference (MD) 5.0, 95%-CI 4.6-to-5.4) and less positive attitudes towards school (MD -1.1, 95% CI -0.56 to -1.85). Poorer attainment in literacy and numeracy persisted at all follow-ups.

CONCLUSIONS

Children aged as young as 4 whose behaviour indicates probable ADHD struggle to cope at school in terms of academic attainment, attendance, classroom behaviour, and attitude towards school when compared to other children. Early identification and intervention to help these children manage in school are needed.

Cost-effectiveness analysis of parenting interventions for the prevention of behaviour problems in children

BACKGROUND

Behavior problems are common among children and place a high disease and financial burden on individuals and society. Parenting interventions are commonly used to prevent such problems, but little is known about their possible longer-term economic benefits. This study modelled the longer-term cost-effectiveness of five parenting interventions delivered in a Swedish context: Comet, Connect, the Incredible Years (IY), COPE, bibliotherapy, and a waitlist control, for the prevention of persistent behavior problems.

METHODS

A decision analytic model was developed and used to forecast the cost per averted disability-adjusted life-year (DALY) by each parenting intervention and the waitlist control, for children aged 5-12 years. Age-specific cohorts were modelled until the age of 18. Educational and health care sector costs related to behavior problems were included. Active interventions were compared to the waitlist control as well as to each other.

RESULTS

Intervention costs ranged between US$ 14 (bibliotherapy) to US$ 1,300 (IY) per child, with effects of up to 0.23 averted DALYs per child (IY). All parenting interventions were cost-effective at a threshold of US$ 15,000 per DALY in relation to the waitlist control. COPE and bibliotherapy strongly dominated the other options, and an additional US$ 2,629 would have to be invested in COPE to avert one extra DALY, in comparison to bibliotherapy.

CONCLUSIONS

Parenting interventions are cost-effective in the longer run in comparison to a waitlist control. Bibliotherapy or COPE are the most efficient options when comparing interventions to one another. Optimal decision for investment should to be based on budget considerations and priority settings.

Promoting mental health and wellbeing in schools: examining Mindfulness, Relaxation and Strategies for Safety and Wellbeing in English primary and secondary schools: study protocol for a multi-school, cluster randomised controlled trial (INSPIRE)

BACKGROUND

There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based, universal prevention programmes are thought to be one way of helping tackle such difficulties. This protocol describes a four-arm cluster randomised controlled trial, investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. The primary outcome for Mindfulness and Relaxation interventions is a measure of internalising difficulties, while Strategies for Safety and Wellbeing will be examined in relation to intended help-seeking. In addition to the effectiveness analysis, a process and implementation evaluation and a cost-effectiveness evaluation will be undertaken.

METHODS AND ANALYSIS

Overall, 160 primary schools and 64 secondary schools will be recruited across England. This corresponds to 17,600 participants. Measures will be collected online at baseline, 3-6 months later, and 9-12 months after the commencement of the intervention. An economic evaluation will assess the cost-effectiveness of the interventions. Moreover, a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, appropriateness and feasibility), and their moderating effects on the outcomes of interest, and perceived impact.

DISCUSSION

This trial aims to address important questions about whether schools' practices around the promotion of mental wellbeing and the prevention of mental health problems can: (1) be formalised into feasible and effective models of school-based support and (2) whether these practices and their effects can be sustained over time. Given the focus of these interventions on mirroring popular practice in schools and on prioritising approaches that present low-burden, high-acceptability to schools, if proved effective, and cost-effective, the findings will indicate models that are not only empirically tested but also offer high potential for widespread use and, therefore, potentially widespread benefits beyond the life of the trial.

TRIAL REGISTRATION

ISRCTN16386254. Registered on 30 August 2018.

Teachers' perceptions of the impact of the Incredible Years® Teacher Classroom Management programme on their practice and on the social and emotional development of their pupils

BACKGROUND

The Incredible Years^® (IY) Teacher Classroom Management (TCM) programme may be an effective way to reduce teacher stress levels, improve child behaviour, and promote positive socio-emotional development. However, few studies have considered what teachers think of the course and how it might work.

AIMS

In this paper, we examine teachers' perceptions of the impact of the TCM programme and how it might work in the classroom.

SAMPLE(S)

Forty-four UK primary school teachers who attended the TCM programme as part of the STARS trial (Ford et al., 2018, Psychol. Med., 49, 828).

METHODS

Focus groups and interviews were held with teachers two months after completing the TCM programme. Thematic analysis (Braun & Clarke, 2006, Qual. Res. Psychol., 3, 77) was employed to explore the subsequent data.

RESULTS

Three main themes were identified: impact on the teacher; on children; and on parent-teacher relationships. Impact on the teacher included a positive change in their ethos. Teachers reported being more able to see things from the child's perspective; placing a greater focus on building positive relationships; thinking before responding; feeling calmer, more confident, and in control; and employing strategies to create positive interactions with children. Teachers felt this had had a positive impact on their pupils' development and relationships with parents. Feedback on whether or not TCM was effective in tackling particularly challenging behaviour was more mixed.

CONCLUSIONS

Our findings suggest that teachers experience the TCM programme as beneficial. This is discussed alongside other qualitative and quantitative studies in this field.

The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial

BACKGROUND

We evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools' important influence on child mental health.

METHODS

A two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes.

TRIAL REGISTRATION

ISRCTN84130388.

RESULTS

Eighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = -1.0; 95% CI-1.9 to -0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health.

CONCLUSIONS

TCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.