A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties

Early detection of students' mental health issues from a traditional daily health observation scheme in Japanese schools and its digitalization

Objective

The implementation of school-based mental health screening offers promise for early detection of mental health issues in children; however, various barriers hinder its widespread adoption. This study aimed to investigate the predictive value of digital data obtained from an established daily health observation scheme in Japanese schools to identify later mental health issues in children.

Methods

Data for the analysis were obtained from 2,433 students enrolled in five public schools. The data acquisition period spanned 76 school days, from September 1, 2022, to December 23, 2022, and student absences were recorded during this period. Depressive and anxiety symptoms were assessed in January 2023. The students' daily physical and emotional health status was recorded as "daily health issue" scores and group-based trajectory modeling was employed to classify the long-term trends in these scores. Additionally, rolling z-scores were utilized to capture variability in daily health issue scores, with z-scores above +1 considered unusual responses.

Results

After 4 months of daily health observations, students' response trends were classified into five trajectory groups. The group experiencing the highest number of daily health issues (Group 5; 5.4% of the sample) exhibited more subsequent depressive and anxiety symptoms compared to the group with fewer issues (Group 1; 47.5%) (incident rate ratio [IRR] = 5.17; 95% confidence interval [CI]: 3.82, 6.99). Group 5 also demonstrated significantly more days of absence than Group 1 (IRR = 2.14, 95% CI: 1.19, 3.85). The average daily health issue scores for the entire period were associated with both depressive/anxiety symptoms and the number of days absent from school (IRR = 1.59, 95% CI: 1.45, 1.73; IRR = 1.18, 95% CI: 1.04, 1.35, respectively). Furthermore, a higher number of unusual responses during the entire period was also associated with more depressive/anxiety symptoms (IRR = 1.10, 95% CI: 1.07, 1.12).

Conclusion

The current study is the first to demonstrate the predictive capability of a traditional daily health observation scheme to identify mental health issues in children. This study highlights the scheme's potential to screen and safeguard children's mental health, emphasizing the importance of digitalization and collaboration with various stakeholders.

School-based intervention for anxiety using group cognitive behavior therapy in Pakistan: a feasibility randomized controlled trial

BACKGROUND

Anxiety and mood disorders are the main cause of illness in people under the age of 25, accounting for 45% of the global disease burden, whereas 4.6% of teenagers aged 15 to 19 are predicted to experience anxiety. Pakistan country, with a population of 200 million, has the worst mental health indicators and fewer than 500 psychiatrists. Despite the existence of various treatments for anxiety, this goes unrecognized and untreated. Due to a lack of awareness, evaluation, prevention, and interventional programs related to being implemented among adolescents in Pakistan, there is a rise in mental health issues in the earlier years of life. It calls for a critical need for indigenous, evidence-based interventions. The present study aimed to evaluate the feasibility of cognitive behavioral therapy (CBT)-based interventions to reduce anxiety symptoms among school children in Pakistan.

METHODS

This study was a pre-post design, two-arm, single-blinded, feasibility, randomized controlled trial. Thirty-four participants (experimental group, n = 17; control group, n = 17) were recruited from four semi-government schools in Rawalpindi with a mean age of 15 (M = 15, SD = 0.73). Two instruments Beck Anxiety Inventory for Youth (BAI-Y II) and BASC-3 Behavioural and Emotional Screening System Student (BESS-SF) were used to assess the severity of symptoms. Participants in the intervention arm received eight-group therapy CBT sessions. A two-way factorial analysis was used to examine the efficacy of CBT in reducing symptom severity.

RESULTS

This study's findings showed that in comparison to the wait-list control group, CBT successfully improved anxiety symptoms among school children while enhancing their social skills.

CONCLUSION

This study will help improve the treatment for anxiety in Pakistan by prioritizing school-based intervention and group-based CBT intervention.

TRIAL REGISTRATION

The trial has been registered at the American Economic Association's registry for randomized controlled trials.

RCT ID

AEARCTR-0009551 . Registered 2022-07-04.

School Nurse Practice: A Descriptive Spanish Study

This study aimed to describe the profile and practices of school nurses working at a network of educational centers in Spain. This was a descriptive study of the documented actions of 107 school nurses between September 2018 and June 2021 in 54 educational centers (55.6% private and 44.4% subsidized). The profile of the school nurses was young (average age 33.8 [standard deviation (SD) = 7.7] years) and predominantly female (91.6%) with a diverse and multidisciplinary education, primarily at the postgraduate level (specialized mainly in emergency care, nursing/school health, and pediatrics/neonatology). They carried out 256,499 interventions. The most frequent types of incidents they treated were accidents (30.4%) and disease-related episodes (22.2%). The interventions were usually brief (average time 7.7 min) and were resolved by the school nurse (99.1%), and the main recipients were students (87.3%). The highest incidence of interventions occurs during breaks between classes. Acute interventions occupied most of the school nurses' time, leaving little opportunity for health education (0.3%). School nurses played an important role in preserving and promoting the health of school populations and cost-savings to healthcare systems with the actions that they performed. Descriptions of these actions are essential when advocating for the continuation and expansion of school nursing services.

A Web-Based Training Program for School Staff to Respond to Self-Harm: Design and Development of the Supportive Response to Self-Harm Program

BACKGROUND

Self-harm is common among adolescents and is a major public health concern. School staff may be the first adults to notice a young person's self-harm and are well placed to provide support or signpost students to help. However, school staff often report that they do not feel equipped or confident to support students. Despite the need, there is a lack of evidence-based training about self-harm for school staff. A web-based training program would provide schools with a flexible and cost-effective method of increasing staff knowledge, skills, and confidence in how to respond to students who self-harm.

OBJECTIVE

The main objective of this study was to coproduce an evidence-based training program for school staff to improve their skills and confidence in responding to students who self-harm (Supportive Response to Self-Harm [SORTS]). This paper describes the design and development process of an initial prototype coproduced with stakeholders to ensure that the intervention meets their requirements.

METHODS

Using a user-centered design and person-based approach, the SORTS prototype was informed by (1) a review of research literature, existing guidelines, and policies; (2) coproduction discussions with the technical provider and subject matter experts (mental health, education, and self-harm); (3) findings from focus groups with young people; and (4) coproduction workshops with school staff. Thematic analysis using the framework method was applied.

RESULTS

Coproduction sessions with experts and the technical provider enabled us to produce a draft of the training content, a wireframe, and example high-fidelity user interface designs. Analysis of focus groups and workshops generated four key themes: (1) need for a training program; (2) acceptability, practicality, and implementation; (3) design, content, and navigation; and (4) adaptations and improvements. The findings showed that there is a clear need for a web-based training program about self-harm in schools, and the proposed program content and design were useful, practical, and acceptable. Consultations with stakeholders informed the iterative development of the prototype.

CONCLUSIONS

SORTS is a web-based training program for school staff to appropriately respond to students who self-harm that is based on research evidence and developed in collaboration with stakeholders. The SORTS program will equip school staff with the skills and strategies to respond in a supportive way to students who self-harm and encourage schools to adopt a whole-school approach to self-harm. Further research is needed to complete the intervention development based on the feedback from this study and evaluate the program's effectiveness. If found to be effective, the SORTS program could be implemented in schools and other youth organizations.

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.

Advancing equity in access to school mental health through multiple informant decision-making

There has been a substantial increase in the number of students with mental health needs, yet significant discrepancies exist in access to timely intervention. Traditional gatekeeping to intervention has been the provenance of single information sources. Multi-informant decision-making is a promising mechanism to improve equitable access. However, critical advancements are necessary to improve decision-making relating to (a) who is identified, (b) what type of need is determined, (c) the type of intervention necessary, and (d) where or under what circumstances to implement the intervention. We review critical components of effective mental health decision-making, contributors to inequities in school mental health services, and offer future directions for research and practice to increase equitable student outcomes.

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.

Potential mental health-related harms associated with the universal screening of anxiety and depressive symptoms in Australian secondary schools

BACKGROUND

Anxiety and depressive disorders typically emerge in adolescence and can be chronic and disabling if not identified and treated early. School-based universal mental health screening may identify young people in need of mental health support and facilitate access to treatment. However, few studies have assessed the potential harms of this approach. This paper examines some of the potential mental health-related harms associated with the universal screening of anxiety and depression administered in Australian secondary schools.

METHODS

A total of 1802 adolescent students from 22 secondary schools in New South Wales, Australia, were cluster randomised (at the school level) to receive either an intensive screening procedure (intervention) or a light touch screening procedure (control). Participants in the intensive screening condition received supervised self-report web-based screening questionnaires for anxiety, depression and suicidality with the follow-up care matched to their symptom severity. Participants in the light touch condition received unsupervised web-based screening for anxiety and depression only, followed by generalised advice on help-seeking. No other care was provided in this condition. Study outcomes included the increased risk of anxiety, depression, psychological distress, decreased risk of help-seeking, increased risk of mental health stigma, determined from measures assessed at baseline, 6 weeks post-baseline, and 12 weeks post-baseline. Differences between groups were analysed using mixed effect models.

RESULTS

Participants in the intensive screening group were not adversely affected when compared to the light touch screening condition across a range of potential harms. Rather, participants in the intensive screening group were found to have a decreased risk of inhibited help-seeking behaviour compared to the light touch screening condition.

CONCLUSIONS

The intensive screening procedure did not appear to adversely impact adolescents' mental health relative to the light touch procedure. Future studies should examine other school-based approaches that may be more effective and efficient than universal screening for reducing mental health burden among students. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12618001539224) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375821 .

The impact of the newly developed school-based 'Digital Health Contact'-Evaluating a health and wellbeing screening tool for adolescents in England

INTRODUCTION

Supporting adolescents with their health and wellbeing is an international public health priority. Schools are well placed to universally detect unmet health needs and support pupils. This study aimed to evaluate the effectiveness of a digital health and wellbeing screening tool, called the 'Digital Health Contact' (DHC) implemented in schools in the East Midlands of England. The DHC, delivered by Public Health Nurses (School Nurses) (PHN(SN)), aims to identify pupils with unmet health needs (via a 'red flag' system) and provide appropriate support.

MATERIALS AND METHODS

Using data from 22 schools which took part in the DHC and 14 schools which did not take part, across three academic years (2018-2020), we conducted a controlled interrupted timeseries analysis with negative binomial regression to explore the effect of the DHC on the number of annual referrals to PHN(SN). Using DHC data from 164 pupils, we further conducted a Difference-in-Difference analysis to explore the impact of 'red flag' and referral via the DHC in Year 9 (age 13-14) on the number of red flags in Year 11 (age 15-16).

RESULTS

Across all schools, the mean annual number of referrals increased over the three year follow-up period. In the adjusted model, the number of referrals was comparable between schools taking part in the DHC and non-participating schools (0.15 referrals [95% CI -0.21, 0.50]). Red flag score was not significantly different among Year 11 pupils, after being referred via the DHC in Year 9 (-0.36 red flags [95% CI -0.97, 0.24]).

DISCUSSION

The DHC, and similar screening tools, have the potential to raise awareness of the health and wellbeing support in schools and provide an additional pathway of referral to this support for pupils with unmet health needs, without replacing the traditional pathway where pupils refer themselves or are referred by teachers.

Psychometric properties of the Distress Questionnaire-5 (DQ5) for measuring psychological distress in adolescents

Screening for psychological distress may assist in identifying at-risk adolescents. While several measures of adolescent psychological distress have been used, most have limited or suboptimal psychometric properties. This study aimed to assess the psychometric properties of the Distress Questionnaire-5 (DQ5), a brief measure of psychological distress, in a large community-based sample of adolescents. Data for the study (n = 3117) were drawn from the baseline and 6-week follow-up assessments of the Future Proofing Study, which collected data from three cohorts of Year 8 students (M = 13.9 years; 48% female) between August 2019 and May 2022. Participants completed the DQ5 at each measurement occasion, as well as measures of depression, generalised and social anxiety, and suicidal ideation. The DQ5 had good fit to a unidimensional construct, with standardised factor loadings ranging between 0.69 and 0.90. The scale had strong criterion (AUC ranged from 0.84 to 0.93) and predictive (AUC ranged from 0.81 to 0.87) validity when compared against indicators for depression, generalised anxiety, social anxiety and suicidal ideation. The DQ5 cut-point of ≥14 had 80% sensitivity and 90% specificity for identifying adolescents meeting symptom thresholds for any of the assessed mental health conditions. Changes in DQ5 scores over 6 weeks had moderate associations with changes in other symptom scales, suggesting sensitivity to change. In conclusion, the DQ5 demonstrates strong psychometric properties and is a reliable measure of psychological distress in adolescents. Given its brevity and ease of interpretation, the DQ5 could be readily used in schools to screen for psychological distress in students.

Population-attributable risk of psychiatric disorders for suicide among adolescents and young adults in Taiwan

BACKGROUND

Youth suicide rates have increased markedly in some countries. This study aimed to estimate the population-attributable risk of psychiatric disorders associated with suicide among Taiwanese youth aged 10-24 years.

METHODS

Data were obtained from the National Death Registry and National Health Insurance (NHI) claims database between 2007 and 2019. Youth who died by suicide were included, and comparisons, 1:10 matched by age and sex, were randomly selected from the Registry for NHI beneficiaries. We used multivariable logistic regression to estimate suicide odds ratios for psychiatric disorders. The population-attributable fractions (PAF) were calculated for each psychiatric disorder.

RESULTS

A total of 2345 youth suicide and 23 450 comparisons were included. Overall, 44.8% of suicides had a psychiatric disorder, while only 7.9% of the comparisons had a psychiatric disorder. The combined PAF for all psychiatric disorders was 55.9%. The top three psychiatric conditions of the largest PAFs were major depressive disorder, dysthymia, and sleep disorder. In the analysis stratified by sex, the combined PAF was 45.5% for males and 69.2% for females. The PAF among young adults aged 20-24 years (57.0%) was higher than among adolescents aged 10-19 years (48.0%).

CONCLUSIONS

Our findings of high PAF from major depressive disorder, dysthymia, and sleep disorder to youth suicides suggest that youth suicide prevention that focuses on detecting and treating mental illness may usefully target these disorders.

Longitudinal pathways between emotional difficulties and school absenteeism in middle childhood: Evidence from developmental cascades

Emotional difficulties are associated with both authorized and unauthorized school absence, but there has been little longitudinal research and the temporal nature of these associations remains unclear. This study presents three-wave random-intercepts panel models of longitudinal reciprocal relationships between teacher-reported emotional difficulties and authorized and unauthorized school absence in 2,542 English children aged 6 to 9 years old at baseline, who were followed-up annually. Minor differences in the stability effects were observed between genders but only for the authorized absence model. Across all time points, children with greater emotional difficulties had more absences, and vice versa (authorized: ρ = .23-.29, p < .01; unauthorized: ρ = .28, p < .01). At the within-person level, concurrent associations showed that emotional difficulties were associated with greater authorized (β = .15-.17, p < .01) absence at Time 3 only, but with less unauthorized (β = -.08-.13, p < .05) absence at Times 1 and 2. In cross-lagged pathways, neither authorized nor unauthorized absence predicted later emotional difficulties, and emotional difficulties did not predict later authorized absence at any time point. However, greater emotional difficulties were associated with fewer unauthorized absences across time (β = -13-.22, p < .001). The implications of these findings are discussed.

Analysis of Protective Factors in Schoolchildren in England Using the Dual-factor Model of Mental Health

The dual-factor approach to mental health was employed to explore levels and interrelations of protective factors associated with resilience in a dataset of 30,841 schoolchildren aged 11-14 in England. ANOVA was used to contrast levels of protective factors between groups (combinations of higher/lower psychopathology and higher/lower wellbeing) and network analysis to explore protective factor interrelations. Levels of protective factors tended to be highest for those who had higher wellbeing and lower psychopathology (termed 'complete mental health'). Those with lower levels of protective factors were split between two subpopulations: having lower wellbeing and higher psychopathology (termed 'troubled'), and having lower wellbeing and lower psychopathology (termed 'vulnerable'). Analysis of the protective factor networks revealed that the four subpopulations of the model were distinguished by both their overall structure and individual node connectivity (the 'complete mental health' subpopulation demonstrated the greatest connectivity), though two were similar: those with higher wellbeing and higher psychopathology (termed 'symptomatic but content') and lower wellbeing and higher psychopathology ('troubled'). The results indicate that while 'vulnerable' and 'symptomatic but content' may be hard to discriminate conceptually, the former may reflect a lower capacity to cope during periods of adversity (i.e., show resilience). Overall, the results encourage a holistic approach to mental health screening, particularly as children with lower wellbeing had lower levels of the protective factors, regardless of their level of psychopathology. Moreover, interventions to improve protective factors associated with positive development in stressed environments may therefore have a greater impact on improving wellbeing than decreasing symptoms of psychopathology.

Is Psychological Distress a Risk Factor or an Outcome of School Violence and Cyberbullying Perpetrated by Adolescents? A Short-Term Longitudinal Panel Study

Although the associations between adolescent psychological distress (i.e., depression, anxiety, and somatization), school violence, and cyberbullying have been examined using cross-sectional data, little evidence from longitudinal panel data exists to determine the temporal association. A two-wave longitudinal panel data with a 10-month interval were obtained from a random sample of 487 Chinese junior high school students (grades 7-9) in Tianjin in Mainland China. The cross-lagged panel analysis showed that adolescent psychological distress in the first wave of the survey was significantly associated with subsequent school violence against peers and teachers in the second wave but not in the opposite direction. Student psychological distress in the first wave of the survey was not significantly associated with cyberbullying perpetration in the second wave and vice versa. The findings suggested that adolescent psychological distress was a risk factor rather than the consequence of violence against peers and teachers in school. However, the temporal associations between adolescent psychological distress and cyberbullying perpetration were non-significant. These findings were relevant to both sex groups. The findings may imply that potential interventions and policies to prevent students from committing school violence should consider reducing students' psychological distress as one of the core elements.

Multi-informant Assessment of Internalizing Concerns: Rater Concordance and Implications for Decision-Making

Rising rates of mental health challenges among youths have become a significant concern following the COVID 19 pandemic. Although strong evidence supports the implementation of universal screening as a preventative approach to address unmet mental health concerns, the research is less clear surrounding the use of such data in decision-making processes when significant discrepancies between informants (e.g., students and teachers) exist. The purpose of the study was twofold. First, the study aimed to determine the degree of rater concordance between teachers and students on students' internalizing concerns. The second objective was to determine whether concordance on internalizing behaviors differs across ages/grades and if this differentially impacts distal (i.e., academic) outcomes. Results indicated that teachers and students demonstrated limited agreement on ratings of internalizing behaviors. However, when students and teachers agreed, higher and more positive emotional behaviors were linked to higher reading/math performance. Furthermore, patterns of informant dis/agreement and relationships between internalizing concerns and academic outcomes were similar across grade levels. Implications and areas for future research are discussed.

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.

Educator-Informed Development of a Mental Health Literacy Course for School Staff: Classroom Well-Being Information and Strategies for Educators (Classroom WISE)

Educators play a critical role in promoting mental health and well-being with their students. Educators also recognize that they lack knowledge and relevant learning opportunities that would allow them to feel competent in supporting student mental health. As such, educators require resources and training to allow them to develop skills in this area. The Mental Health Technology Transfer Center (MHTTC) Network partnered with the National Center for School Mental Health at the University of Maryland School of Medicine to develop Classroom Well-Being and Information for Educators (WISE), a free, three-part mental health literacy training package for educators and school staff that includes an online course, video library, and resource collection. The Classroom WISE curriculum focuses on promoting positive mental health in the classroom, as well as strategies for recognizing and responding to students experiencing mental health related distress. This paper describes the curriculum development process, including results of focus groups and key informant interviews with educators and school mental health experts. Adoption of Classroom WISE can help educators support student mental health and assist in ameliorating the youth mental health crisis.

Cost-Effectiveness of 5 Public Health Approaches to Prevent Eating Disorders

INTRODUCTION

Eating disorders cause suffering and a high risk of death. Accelerating the translation of research into implementation will require intervention cost-effectiveness estimates. The objective of this study was to estimate the cost-effectiveness of 5 public health approaches to preventing eating disorders among adolescents and young adults.

METHODS

Using data from 2001 to 2017, the authors developed a microsimulation model of a closed cohort starting at the age of 10 years and ending at 40 years. In 2021, an analysis was conducted of 5 primary and secondary prevention strategies for eating disorders: school-based screening, primary care‒based screening, school-based universal prevention, excise tax on over-the-counter diet pills, and restriction on youth purchase of over-the-counter diet pills. The authors estimated the reduction in years lived with eating disorders and the increase in quality-adjusted life-years. Intervention costs and net monetary benefit were estimated using a threshold of $100,000/quality-adjusted life year.

RESULTS

All the 5 interventions were estimated to be cost-saving compared with the current practice. Discounted per person cost savings (over the 30-year analytic time horizon) ranged from $63 (clinic screening) to $1,102 (school-based universal prevention). Excluding caregiver costs for binge eating disorder and otherwise specified feeding and eating disorders substantially reduced cost savings (e.g., from $1,102 to $149 for the school-based intervention).

CONCLUSIONS

A range of public health strategies to reduce the societal burden of eating disorders are likely cost saving. Universal prevention interventions that promote healthy nutrition, physical activity, and media use behaviors without introducing weight stigma may prevent additional negative health outcomes, such as excess weight gain.

Exploring young people's perspectives on mental health support: A qualitative study across three geographical areas in England, UK

Improving young people's (YP) mental health and well-being is a global public health priority. Despite continued commitment within the UK policy agenda to improve the mental health and well-being of YP, the incidence of mental health issues continues to rise. This has been further compounded by the outbreak of COVID-19 which has disproportionately affected YP in the most socioeconomically disadvantaged areas. Understanding YP's perspectives on what supports their mental health is important to develop policies that meet their needs. We conducted focus groups (n = 18 with 42 YP aged 13-21) in three geographical areas with high levels of deprivation in England, UK. Recruited through six local youth organisations, each group of YP took part in three interlinked focus groups designed to explore their perceptions of what impacts their health in their local area, and their understandings of health inequalities through participatory methods. Throughout their discussions, YP foregrounded the significance of mental health and mental health support structures. YP perceived challenges to accessing mental health provision and an unmet need for support within their local communities. Alongside this, YP consistently highlighted the importance of youth groups for promoting good mental health and mitigating challenges to poor mental health. However, ongoing cuts to the voluntary sector and universal services continue to impact areas and individuals in the greatest need. In the face of deficits in formal mental health support, our findings highlight the pressing need for increased investment in services focused on prevention (such as youth groups) in areas of high deprivation.

Risk factors for nonfatal self-harm and suicide among adolescents: two nested case-control studies conducted in the UK Clinical Practice Research Datalink

BACKGROUND

The characteristics of adolescents who die by suicide have hitherto been examined in uncontrolled study designs, thereby precluding examination of risk factors. The degree to which antecedents of nonfatal self-harm and suicide at young age differ remains unknown.

METHOD

We delineated two nested case-control studies of patients aged 10-19 years using the Clinical Practice Research Datalink with interlinked hospital and national mortality records. Cases were adolescents who between 1st January 2003 and 31st December 2018 had died from suicide (N = 324) - study 1; experienced their first self-harm episode (N = 56,008) - study 2. In both studies, cases were matched on sex, age and practice-level deprivation quintile to 25 controls. By fitting conditional logistic regression, we examined how risks varied according to psychiatric diagnoses, prescribed psychotropic medication, patterns of clinical contact and area-level deprivation.

RESULTS

Suicides occurred more often among boys (66%), but self-harm was more common in girls (68%). Most individuals who self-harmed or died from suicide presented to their GP at least once in the preceding year (85% and 75% respectively). Only a third of cases had one of the examined diagnostic categories recorded. Depression was most strongly associated with elevated risks for both outcomes (self-harm: OR 7.9; 95% CI 7.8-8.2; suicide: OR 7.4; 95% CI 5.5-9.9). Except for autism spectrum disorder, all other diagnostic categories were linked with similar risk elevations for self-harm as for suicide. Whilst self-harm risk rose incrementally with increasing levels of area-level deprivation, suicide risks did not.

CONCLUSIONS

We observed few marked differences in risk factor profiles for nonfatal self-harm versus suicide. As most adolescents who had harmed themselves or died by suicide were known to services in the preceding year, their underlying pathology may not be adequately identified and treated. Our findings highlight the need for a multiagency approach to treatment and prevention.

Stability of mental disorder prevalence estimates among school-aged children and adolescents: findings from the community-based project to learn about youth-mental health (PLAY-MH) and replication-PLAY-MH (Re-PLAY-MH), 2014-2017

PURPOSE

This study evaluated the stability over time of prevalence estimates of mental disorders among school-aged children from the same community.

METHODS

We compared screening status and weighted prevalence of selected mental disorders from the two-stage school-based South Carolina Project to Learn About Youth-Mental Health (Time 1) and its replication study (Time 2) conducted between 2014 and 2017. During stage 1, two teacher screeners were used to group students into high or low risk for a mental disorder. During stage 2, parents of selected students completed a structured diagnostic interview to assess whether their child met criteria for specific disorders.

RESULTS

For stage 1, 19.9% of students screened as high risk for a mental disorder at Time 2 compared to 17.8% at Time 1. Among students included at both timepoints, 9.1% screened as high risk at both timepoints while screening status changed for 20.7%. The overall prevalence of included mental disorders was approximately 18% at both time points There were no differences (P-values >.05) in prevalence of individual mental disorders between Time 1 (range:0.3%-6.7%) and Time 2 (range:1.2%-7.7%).

CONCLUSIONS

Study findings demonstrate that similar methodology yielded similar prevalence estimates of mental disorders and can inform community-level planning for improving mental health in children.

Mental Health and Positive Development Prevention Interventions: Overview of Systematic Reviews

CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10-19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5-10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5-14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5-14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

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.

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.

Suicide prevention for international students: a scoping review protocol

INTRODUCTION

The existing literature demonstrates that international students face a variety of stressors and barriers that can heighten the risk of suicide. However, up to now, no research has sought to summarise the available literature on the prevention strategies for suicide for international students in tertiary education. This document provides a scoping review protocol that aims to systematically chart and synthesise the published, unpublished and grey literature on the prevention strategies for suicide in the international student community.

METHODS AND ANALYSIS

The enhanced six-stage methodological framework for scoping reviews of Arksey and O'Malley will be used. Two main research questions guide the review: (1) What is the extent, range and nature of the evidence regarding suicide prevention for international students? and (2) What suicide prevention strategies are promising for targeting international students? Peer-reviewed and non-peer-reviewed articles, reports and policy documents will be eligible to be included in the review with no limits on publication date. Electronic searches of the CINAHL, ERIC, Medline, PsycInfo and ProQuest will be conducted to identify relevant academic publications. Grey literature searches will be undertaken on relevant databases as well as government and organisational websites. The reporting of the review will follow the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Criteria for evidence inclusion and exclusion will be used during literature screening and mapping. Screening and data charting of the published and grey literature will be conducted by three reviewers. Relevant stakeholders and experts will be consulted regarding the findings and their input will be integrated into the final report.

ETHICS AND DISSEMINATION

The study will be disseminated through a peer-reviewed journal, conference presentations and consultations with relevant stakeholders in policy and professional settings. Ethical approval is not required for this review.

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.

How can the education sector support children’s mental health? Views of Australian healthcare clinicians

Objectives

Policy makers in developed countries have long considered the education system an avenue for supporting mental health care for children. Whilst educators have identified many challenges to providing this support (e.g. non-core role, stigma, overcrowded curriculum), understanding clinicians’ views on the role of educators and schools and how clinicians and schools could work together to achieve good mental health outcomes are important questions. However, clinician voices in how schools and health should work together for children’s mental health care are frequently missing from the debate. We aimed to report clinicians’ views about how the education system could support student’s mental health and improve access to mental health care for children and adolescents.

Methods

143 clinicians (approximately 35 each of child and adolescent psychiatrists, pediatricians, child psychologists and general practitioners (GPs)) from the states of Victoria and South Australia participated in semi-structured phone interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study aims.

Findings

Key themes emerged: (1) The role of schools in supporting individual children; (2) School based programs to support children and families; and (3) Challenges of implementing these suggestions. Clinicians across all professional groups suggested the education system could play an important role in improving access to mental health services through harnessing existing staff or co-locating mental health clinicians. They also suggested schools could identify at risk children and implement coping and social skills programs.

Conclusions

Schools and educators could play a key role in prevention and early intervention of children’s mental health problems. However, before recommending exactly how to do this, key evidence gaps need to be addressed.

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.

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.

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.

A cluster randomised controlled trial of a web-based youth mental health service in Australian schools

BACKGROUND

Secondary schools have attempted to address gaps in help-seeking for mental health problems with little success. This trial evaluated the effectiveness of a universal web-based service (Smooth Sailing) for improving help-seeking intentions for mental health problems and other related outcomes among students.

METHODS

A cluster randomised controlled trial was conducted to evaluate the 12-week outcomes of the Smooth Sailing service among 1841 students from 22 secondary schools in New South Wales, Australia. Assignment was conducted at the school level. The control condition received school-as-usual. The primary outcome was help-seeking intentions for general mental health problems at 12-weeks post-baseline. Secondary outcomes included help-seeking behaviour, anxiety and depressive symptoms, psychological distress, psychological barriers to help-seeking, and mental health literacy. Data were analysed using mixed linear models. This trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12618001539224).

FINDINGS

At 12-weeks post-baseline, there was a marginal statistical difference in the relative means of help-seeking intentions (effect size=0•10, 95%CI: -0•02-0•21) that favoured the intervention condition. Help-seeking from adults declined in both conditions. There was a greater reduction in the number of students who "needed support for their mental health but were not seeking help" in the intervention condition (OR: 2•08, 95%CI: 1•72-2.27, P<•0001). No other universal effects were found. Participants found the service easy to use and understand; However, low motivation, time, forgetfulness, and lack of perceived need were barriers to use.

INTERPRETATION

Smooth Sailing led to small improvements in help-seeking intentions. Refinements are needed to improve its effectiveness on other mental health outcomes and to increase student uptake and engagement.

FUNDING

HSBC and Graf Foundation.

Teacher Nomination of School-aged Children for Mental Health Services in a Low and Middle Income Country

Background: Knowledgeable in child development, primary school teachers in low- and middle-income countries (LMICs) have the potential to identify their students needing mental health care. Objective: We evaluated whether teachers in Darjeeling, India can accurately nominate school-aged children for mental health services after training and aided by a novel tool. Methods: In 2018, 19 primary school teachers from five low-cost private (LCP) schools in rural Darjeeling were trained to nominate children needing care. Teachers evaluated all of their students aided by a novel tool, 'Behavior Type and Severity Tool' (BTST), completed the Achenbach Teacher Report Form (TRF) as a mental health status reference standard, and nominated two students for care. Sensitivity and specificity of being nominated compared to TRF overall and subdomain scores were calculated. BTST performance was determined by comparing BTST and TRF scores and creating Receiver Operating Characteristic curves to determine optimal cutoffs. Multivariable regression models were used to identify demographic predictors of teacher accuracy using the BTST. Results: For students demonstrating a clinical or borderline score in at least one TRF subdomain, the sensitivity (72%) and specificity (62%) of teacher nomination were moderately high. BTST overall scores and TRF Total Problem scores were correlated (Spearman's ρ = 0.34, p < 0.0001), as were all subdomains. For the TRF Total Problem score, a maximum Youden's J of 0.39 occurred at BTST cutoff >4 for borderline struggles and 0.54 at the BTST cutoff >6 for clinical struggles. Younger teacher age, less education, less formal education training, and more years of experience were positively associated with teacher accuracy. Conclusions: With training and a simple decision support tool, primary school teachers in an LMIC nominated students for mental health services with moderate accuracy. With the BTST being weakly accurate, teachers' judgment largely accounted for the moderate accuracy of nominations.

Teachers' concerns about pupils' mental health in a cross-sectional survey of a population sample of British schoolchildren

BACKGROUND

Schools are becoming central to the identification and referral of children and young people with poor mental health. Understanding how well a teacher concern predicts mental disorder in a child or young person is important for mental health teams who need to respond to referrals.

METHOD

This secondary analysis of the 2004 British Child and Adolescent Mental Health Survey used the first item of the Strengths and Difficulties Questionnaire (SDQ) Impact subscale to indicate concern about a child or young person's mental health. Mental disorder according to DSM IVR criteria was assessed using the multi-informant Development and Well-Being Assessment. We compared the proportion with and without mental disorder according to the presence or absence of teacher concern.

RESULTS

Teacher concern was moderately predictive (49% with teacher concern had a disorder) and sensitive (teacher concern present among 56% with disorder), while lack of teacher concern was highly predictive (only 5% had disorder) and specific (94% no disorder). Teacher concern was associated with significantly poorer mental health (mean teacher SDQ total difficulty score 19.6, SD 5.6 with disorder, mean 15.0; SD 5.1 if no disorder) compared to children without teacher concern (mean 9.6, SD 5.5 with disorder, and 4.9; SD 4.3 if no disorder; F (3, 5,931) = 1527.228, p = .001). If both teacher and parents were concerned, the child or young person was much more likely to have a disorder.

CONCLUSION

A lack of teacher concern can reassure mental health practitioners in the vast majority of cases. While teacher concern does identify those with poorer mental health, it is only moderately predictive of a disorder. When concerned about a child or young person, discussions with parents or others who know them may help teachers identify those who most need support.

KEY PRACTITIONER MESSAGE

The emphasis on schools as a major setting to provide support and identify the need for referral to specialist mental health services means service commissioners, providers and practitioners could benefit from insight into how predictive a teacher's concern is of childhood mental health conditions and how this may vary with the type of disorder If teachers are not concerned about a child, practitioners can be reassured that there is unlikely to be a significant problem with their mental health, although this will be less certain in schools whose pupils are likely to have a higher than average levels of difficulty Teacher concerns do not necessarily differentiate between clinically impairing and mild/ moderate mental health difficulties, but do identify children in poorer mental health Asking for corroboration of concern from other sources increases the strength of the association to severe mental health disorders.

Evaluating the Cost of Prevention Programming and Universal Screening with Discrete Event Simulation

Discrete Event Simulation (DES) is a novel system modeling technique that allows for the evaluation of the potential costs and personnel needed for mental health services in school. A case study is presented to illustrate how DES could be used by a school's decision makers to help plan for implementation of an integrated mental health service model. Discrete Event Simulation was used to model the personnel, time, and costs of an integrated mental health service model within a school setting. In addition, costs are calculated and then compared to a business as usual model. Data from the present investigation indicate substantial cost savings of implementing a prevention oriented mental health intervention model within a school setting. In a school of 1000 students, the prevention model could result in an annual cost savings of approximately $30,000 as well as a 50% reduction in disciplinary referrals and 22% reduction in suspensions. Results from the present investigation indicate substantial savings in financial resources and overall numbers of disciplinary infractions when implementing a prevention model. The DES allows for customization of personnel and time to modify the model and resulting output to local conditions. These data may allow school administrators to modify resources to meet student needs. In addition, cost data can help address some of the common implementation barriers associated with adoption of universal screening and preventative mental health services.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

BACKGROUND

Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings.

METHODS

Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted.

RESULTS

Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation.

CONCLUSIONS

Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges.

KEY PRACTITIONER MESSAGE

Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Acceptability and Feasibility of Early Identification of Mental Health Difficulties in Primary Schools: A Qualitative Exploration of UK School Staff and Parents’ Perceptions

One in eight children aged 5–19 years in the UK suffer from a psychiatric disorder, while fewer than 35% are identified and only 25% of children access mental health services. Whilst government policy states that primary schools are well-placed to spot the early warning signs of mental health issues in children, the implementation of early identification methods in schools remains under-researched. This study aims to increase understanding of the acceptability and feasibility of different early identification methods in this setting. Four primary schools in the East of England in the UK participated in a qualitative exploration of views about different methods that might enhance the early identification of mental health difficulties (MHDs). Twenty-seven staff and 20 parents took part in semi-structured interviews to explore current and future strategies for identifying pupils at risk of experiencing MHDs. We presented participants with four examples of identification methods selected from a systematic review of the literature: a curriculum-based approach delivered to pupils, staff training, universal screening, and selective screening. We used NVivo to thematically code and analyse the data, examining which models were perceived as acceptable and feasible as well as participants’ explanations for their beliefs. Three main themes were identified; benefits and facilitators; barriers and harms, and the need for a tailored approach to implementation. Parents and staff perceived staff training as the most acceptable and feasible approach to systematic identification, followed by a curriculum-based approach. Universal and selective screening garnered mixed responses. Findings suggest that a systematic and tailored approach to early identification would be most acceptable and feasible, taking into consideration school context. Teacher training should be a core component in all schools.

The Strengths and Difficulties Questionnaire Predicts Concurrent Mental Health Difficulties in a Transdiagnostic Sample of Struggling Learners

Children and adolescents with developmental problems are at increased risk of experiencing mental health problems. The Strengths and Difficulties Questionnaire (SDQ) is widely used as a screener for detecting mental health difficulties in these populations, but its use thus far has been restricted to groups of children with diagnosed disorders (e.g., ADHD). Transdiagnostic approaches, which focus on symptoms and soften or remove the boundaries between traditional categorical disorders, are increasingly adopted in research and practice. The aim of this study was to assess the potential of the SDQ to detect concurrent mental health problems in a transdiagnostic sample of children. The sample were referred by health and educational professionals for difficulties related to learning (N = 389). Some had one diagnosis, others had multiple, but many had no diagnoses. Parent-rated SDQ scores were significantly positively correlated with parent ratings of mental health difficulties on the Revised Child Anxiety and Depression Scale (RCADS). Ratings on the SDQ Emotion subscale significantly predicted the likelihood of having concurrent clinical anxiety and depression scores. Ratings on the Hyperactivity subscale predicted concurrent anxiety levels. These findings suggest the SDQ could be a valuable screening tool for identifying existing mental health difficulties in children recognized as struggling, as it can be in typically developing children and those with specific diagnoses.

The Impact of Referral to Mental Health Services on Suicide Death Risk in Adolescent Suicide Survivors

Objectives

This study aims to examine the effect of adolescent suicide survivors' experience on suicide death risk, and the effect of referral to mental health services (hereafter referral) in this regard.

Methods

This study used the data of 878 suicide-deceased and suicide-attempted adolescents aged 8-19 years, managed by the Suicide and School Mental Health Institute from 2016 to 2018.

Results

Regression analysis for main effects showed that although suicide experience had no direct effect on suicide death, non-referral status was associated with a greater risk of death by suicide. While the "non-suicide survivor with non-referral" and "suicide survivor with non-referral" groups showed 1.87 [adjusted odds ratio=1.87, 95% confidence interval (CI)=1.21-2.89] and 4.59 (adjusted odds ratio= 4.59, 95% CI=2.02-10.42) times higher odds of suicide death, respectively, the "suicide survivor with referral" group showed no difference compared to the "non-suicide survivor with referral" group.

Conclusion

From these findings, there is a need to strengthen referral to mental health services and apply complicated grief treatment to improve the mental health of adolescent suicide survivors.

Advancing methodology for scoping reviews: recommendations arising from a scoping literature review (SLR) to inform transformation of Children and Adolescent Mental Health Services

BACKGROUND

There is consensus that health services commissioning and clinical practice should be driven by scientific evidence. However, workload pressures, accessibility of peer reviewed publications and skills to find, appraise, and synthesise relevant evidence are often cited as barriers to uptake of research evidence by practitioners and commissioners alike. In recent years a growing requirement for rapid evidence synthesis to inform commissioning decisions about healthcare service delivery and provision of care contributed to an increasing popularity of scoping literature reviews (SLRs). Yet, comprehensive guidelines for conducting and reporting SLRs are still relatively scarce.

METHODS

The exemplar review used as a worked example aimed to provide a readily available, comprehensive, and user-friendly repository of research evidence for local commissioners to help them make evidence-informed decisions about redesigning East of England Children and Adolescent Mental Health Services. In conducting the review, we were broadly guided by Arksey and O'Malley's framework, however some modifications were made at different stages to better reflect the largely pragmatic objective of this review. This paper compares the methodology used with existing methodological frameworks for scoping studies, to add to the existing knowledge base.

RESULTS

We proposed the following advancements to the existing SLR frameworks: (i) Assemble a research team with complementary skills and expertise; (ii); Draw on expertise of external partners, particularly practitioners, decision-makers and commissioners who will be translating findings into practice; (iii) Pre-register the review protocol. Keep a detailed record of all steps and decisions and consider how they would impact on generalisability and utility of review findings; (iv) Use systematic procedures for literature searchers, selection of studies, data extraction and analysis; (v) If feasible, appraise the quality of included evidence; (vi) Be transparent about limitations of findings.

CONCLUSIONS

Despite some methodological limitations, scoping literature reviews are a useful method of rapidly synthesising a large body of evidence to inform commissioning and transformation of CAMHS. SLRs allow researchers to start with a broader questions, to explore the issue from different perspectives and perhaps find more comprehensive solutions that are not only effective, but also accounted for their feasibility and acceptability to key stakeholders.

Emotional disorder and absence from school: findings from the 2004 British Child and Adolescent Mental Health Survey

Emotional disorder may be associated with absence from school, but the existing evidence is methodologically weak. We studied the relationships between anxiety, depression and emotional difficulties, and school absence (total, authorised and unauthorised) using data from the 2004 British Child and Adolescent Mental Health Survey (BCAMHS). The BCAMHS was a cross-sectional, community survey of 7977 5- to 16-year-olds. Emotional disorder was assessed using the Development and Wellbeing Assessment (DAWBA), and emotional difficulties using the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents. Teachers reported days absent in the previous school term. Multivariable negative binomial regression was used to examine the impact of emotional disorder and difficulties on absence. Age, gender and general health were explored as moderators. Anxiety, depression and emotional difficulties were associated with higher rates of all types of absence [rate ratios for total absence: anxiety 1.69 (1.39-2.06) p < 0.001; depression 3.40 (2.46-4.69) p < 0.001; parent-reported emotional difficulties 1.07 (1.05-1.10) p < 0.001; teacher-reported emotional difficulties 1.10 (1.08-1.13) p < 0.001]. The strongest association was observed for depression and unauthorised absence. Relationships were stronger for secondary compared to primary school children. Health and educational professionals should be aware that children with poor attendance may be experiencing emotional ill health, regardless of absence type. The absence may provide a useful tool to identify those who require additional mental health support. Findings highlight the widespread burden of emotional disorder and the need to support those with emotional ill health in continuing to access education.

Evaluation of a screening algorithm using the Strengths and Difficulties Questionnaire to identify children with mental health problems: A five-year register-based follow-up on school performance and healthcare use

BACKGROUND

Treatment of mental health problems (MHP) is often delayed or absent due to the lack of systematic detection and early intervention. This study evaluates the potential of a new screening algorithm to identify children with MHP.

METHODS

The study population comprises 2,015 children from the Copenhagen Child Cohort 2000 whose mental health was assessed at age 11-12 years and who had no prior use of specialised mental health services. A new algorithm based on the Strengths and Difficulties Questionnaire (SDQ) is utilised to identify MHP by combining parent-reported scores of emotional and behavioural problems and functional impairments. The screening is done on historical data, implying that neither parents, teachers nor health care professionals received any feedback on the screening status. The screening status and results of an IQ-test were linked to individual-level data from national registries. These national registers include records of each child's school performance at the end of compulsory schooling, their health care utilisation, as well as their parents' socio-economic status and health care utilisation.

RESULTS

10% of the children screen positive for MHP. The children with MHP achieve a significantly lower Grade Point Average on their exams, independently of their IQ-score, perinatal factors and parental characteristics. On average, the children with MHP also carry higher health care costs over a five-year follow-up period. The higher health care costs are only attributed to 23% of these children, while the remaining children with MHP also show poorer school performance but receive no additional health care.

CONCLUSIONS

The results demonstrate that children with MHP and a poor prognosis can be identified by the use of the brief standardised questionnaire SDQ combined with a screening algorithm.

Acceptability of screening for mental health difficulties in primary schools: a survey of UK parents

BACKGROUND

Many children and young people experiencing mental health difficulties (MHD) do not access care, often due to inadequate identification. Schools have a unique potential to improve early identification; however, evidence is limited regarding the acceptability of school-based identification programmes. This study aimed to examine parents' beliefs about the acceptability of school-wide MHD screening in primary schools.

METHODS

We collaborated with experts in school-based mental health to develop a questionnaire to measure parental attitudes toward school-wide MHD screening. The questionnaire contained 13 items relating to acceptability; three open-text boxes for comments on harms, benefits, and screening in general; and four questions that captured demographic information. Parents of children attending four primary schools in Cambridgeshire and Norfolk completed the questionnaire. We calculated counts, percentages, and means for each statement, and analysed responses to open-ended questions using content analysis.

RESULTS

Two hundred ninety parents returned the questionnaire across the four schools (61% response rate). In the 260 questionnaires analysed, a total of 254 parents (98%) believed that it is important to identify MHD early in life, and 251 (97%) believed that schools have an important role in promoting pupils' emotional health. The majority of parents (N = 213; 82%) thought that screening would be helpful, although 34 parents (13%) thought that screening would be harmful. Perceived harms of screening included inaccurate identification, stigmatisation, and low availability of follow-up care. There was no clear consensus regarding how to obtain consent or provide feedback of screening results. There were no significant differences in responses according to ethnicity, gender, age, or school.

CONCLUSIONS

Results suggest that most parents within the socio-demographic context of our study will accept MHD screening within primary schools, and that school-based screening is viable from the perspective of parents. The comments provided about potential harms as well as suggestions for programme delivery are relevant to inform the development and evaluation of acceptable and sustainable school-based identification models. Implementation and scale-up of such programmes will require further understanding of the perspectives of mental health professionals, school staff, and the general public as well as further evaluation against the established standards for identification programmes.