Does a socio-ecological school model promote resilience in primary schools?

A call to create evidence-based mental health promotion interventions for youth that are equitable across ethnic/racial subgroups: Advocates 4-ALL Youth

Background

Adolescents from historically racial and ethnic minoritized and low-income communities have higher rates of early-life and chronic difficulties with anxiety and depression compared to non-Hispanic White youth. With mental health distress exacerbated during and in the wake of the COVID-19 pandemic, there is a need for accessible, equitable evidence-based programs that promote psychological well-being, strengthen one's ability to adapt to adversity, and build self-efficacy prior to adolescence.

Methods

An evidenced-based resiliency-focused health coaching intervention was adapted using a health equity implementation framework to meet the needs of a Title I elementary school in rural Alabama (AL) that serves over 80% Black and Hispanic students. To ensure that the program met local community needs while maintaining core program educational activities, all adaptations were documented utilizing a standard coding system.

Results

Leveraging an existing academic-community partnership with Auburn University and a local AL school district, a new program, Advocates 4-All Youth (ALLY), was created. Three major adaptations were required: (1) the use of local community volunteers (ALLYs) to deliver the program versus health coaches, (2) the modification of program materials to meet the challenge of varying levels of general and health-related literacy, and (3) the integration of the Empower Action Model to target protective factors in a culturally-tailored delivery to ensure key program outcomes are found equitable for all students.

Conclusion

With continued increases in youth mental health distress, there is a need for the development of universal primary prevention interventions to promote mental well-being and to strengthen protective factors among youth from historically disadvantaged backgrounds. ALLY was created to meet these needs and may be an effective strategy if deemed efficacious in improving program outcomes.

Digital training for building resilience: Systematic review, meta-analysis, and meta-regression

Resilience is learnable and broadly described as an individual's adaptive coping ability, its potential value for stress reduction must be explored. With a global coronavirus pandemic, innovative ways to deliver resilience training amidst heightened mental health concerns must be urgently examined. This systematic review aimed to (1) evaluate the effectiveness of digital training for building resilience and reducing anxiety, depressive and stress symptoms and (2) to identify essential features for designing future digital training. A three-step search was conducted in eight electronic databases, trial registries and grey literature to locate eligible studies. Randomised controlled trials examining the effects of digital training aimed at enhancing resilience were included. Data analysis was conducted using the Stata version 17. Twenty-two randomised controlled trials involving 2876 participants were included. Meta-analysis revealed that digital training significantly enhanced the participants' resilience with moderate to large effect (g = 0.54-1.09) at post-intervention and follow-up. Subgroup analyses suggested that training delivered via the Internet with a flexible programme schedule was more effective than its counterparts. This review supports the use of digital training in improving resilience. Further high-quality randomised controlled trials with large sample size are needed.

Resilience Programs for Children and Adolescents: A Systematic Review and Meta-Analysis

Resilience may be defined as the ability to recover and adapt to adverse situations. Given that resilience involves cognitive and behavioral aspects, it could be promoted based on strategies that favor them, especially during childhood and adolescence. As a result, several resilience-focused programs have been developed and studied. This systematic review of Randomized Controlled Trials (RCTs) aimed to assess resilience-focused programs for children (<12 years old) and adolescents (12-22 years old) compared to active (treatment as usual, other program modalities, and educational curriculum at school) or inactive (waiting list, no treatment) control groups. We performed a systematic review of meta-analyses of RCTs. The following databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and PsycINFO. Two authors independently selected the studies, extracted the data, and assessed the studies' risk of bias. Meta-analyses of random effects were conducted to calculate the standard mean differences (SMD) and 95% confidence interval (CI) of program effectiveness. Of the 17 RCTs that met the inclusion criteria, 13 provided sufficient data to assess the effectiveness of the programs after their implementation. Meta-analyses indicated overall effectiveness of the programs in promoting resilience (SMD = 0.48, 95% CI [0.15, 0.81], p = 0.0077). The subgroup analysis indicated effectiveness only among adolescents' resilience (SMD = 0.48, 95% CI [0.08, 0.88], p = 0.02). The follow-up analysis also indicated evidence of continuation of results within a period of up to 6 months up (SMD = 0.12, 95% CI [-0.44, 0.69], p = 0.02). These results indicated the effectiveness of promoting resilience, especially in adolescents, and its continuation in follow-up analyses. These findings are promising in the field of resilience programs; however, further studies are necessary to analyze the different possible characteristics of programs and their results. Clinical Trial Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020179874], [CRD42020179874].

Child and Adolescent Mental Health and Resilience-Focussed Interventions: A Conceptual Analysis to Inform Future Research

Internationally, the mental health of children and adolescents is undoubtedly an important construct of theoretical, clinical, and policy level concern. Worldwide, five mental disorders (depression, alcohol misuse, bipolar affective disorder, schizophrenia, and obsessive-compulsive disorder) represent half of the 10 leading causes of disability and premature death; with mental disorders accounting for 15–30% of disability adjusted life years in the first three decades of life. This provides a solid rational founded in implications for population health as to why reducing and preventing mental health problems in children and adolescents deserves attention. Past research has indicated interventions focussed on building resilience through strengthening protective factors may offer the potential to address mental health problems in children and adolescents, and in particular aid in reducing such problems during times of increased risk or adversity. With childhood and adolescence being critical periods of development, there is a need to reflect on the strengths and limitations of resilience-focussed interventions and anticipated future needs of the world’s youth. This conceptual analysis identifies a number of future research directions that may meaningfully add to the evidence base and improve implementation, evaluation, and impact of resilience-focussed interventions. These largely relate to refining the understanding of how resilience protective factors relate to mental health problems in children and adolescents. Important issues and potential opportunities to improve the related research field include improved reporting of intervention content; improved measurement of resilience protective factors in intervention trials; continued reporting and review of evidence of association between protective factors and mental health outcomes; and incorporation of mediation analysis within intervention trials. There is a need for further intervention studies in this space to be conducted as rigorous trials of resilience-focussed approaches based on such evidence of association, with clearly posited mechanisms of change, and inclusive of analysis of differential intervention effects. The suggested implications for research made in this conceptual analysis will aid in improving the quality of the evidence base relevant to the fostering of resilience and prevention of mental health problems in children and adolescents.

Resilience-promoting policies and contexts for children of color in the United States: Existing research and future priorities

The health status of children in the United States varies by racial and ethnic, shaped by an interrelated set of systems that disadvantage children of color in the United States. In this article, we argue for a broad view of resilience, in both research and policy, that views resilience not just as a property of individuals but also as a characteristic of social contexts and policies. Accordingly, we describe the empirical evidence for policies and contexts as factors that can improve health among children and families that are deprived of equal opportunities and resources due to structural racism. We discuss the evidence and opportunities for policies and interventions across a variety of societal systems, including programs to promote economic and food security, early education, health care, and the neighborhood and community context. Based on this evidence and other research on racism and resilience, we conclude by outlining some directions for future research.

How 'The Daily Mile™' works in practice: A process evaluation in a UK primary school

Over 75% children in the United Kingdom fail to achieve recommended levels of physical activity. Successful implementation of 'The Daily Mile™', a school-based physical activity intervention, could promote activity. We examined factors instrumental to replication and/or wider implementation of 'The Daily Mile' through application of a two phase multi-method process evaluation. Phase one: 75 children (mean age seven years eight months) from one East Midland primary academy trialled the intervention. Data collected were self-report logs, perceived exertion scores and structured observation. Phase two: a sub-sample of 18 stakeholders participated in focus groups which were analysed using framework method. Teachers delivered 'The Daily Mile' on 93.6% of school days. An average of 95.2% of students participated, 94.2% completed recommended 15 minutes, 94.3% to a moderate-to-vigorous level. Three themes emerged in focus groups; embedding 'The Daily Mile' into practice, creating the right physical environment and building relationships/promoting a supportive climate. With systematic organisation and planning, 'The Daily Mile' could emerge as an integrated means of increasing physical activity. A supportive climate and factors that promote resilience are key facilitators. Further research is needed to establish outcomes and cost-effectiveness.

Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting

OBJECTIVE

To examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents.

METHOD

Eligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-≤12 months; long: >12 months), and gender (narrative).

RESULTS

A total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems.

CONCLUSION

The findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research.

SYSTEMATIC REVIEW PROTOCOL AND REGISTRATION

Systematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Effectiveness of a pragmatic school-based universal intervention targeting student resilience protective factors in reducing mental health problems in adolescents

Worldwide, 10-20% of adolescents experience mental health problems. Strategies aimed at strengthening resilience protective factors provide a potential approach for reducing mental health problems in adolescents. This study evaluated the effectiveness of a universal, school-based intervention targeting resilience protective factors in reducing mental health problems in adolescents. A cluster randomised controlled trial was conducted in 20 intervention and 12 control secondary schools located in socio-economically disadvantaged areas of NSW, Australia. Data were collected from 3115 students at baseline (Grade 7, 2011), of whom 2149 provided data at follow up (Grade 10, 2014; enrolments in Grades 7 to 10 typically aged 12-16 years; 50% male; 69.0% retention). There were no significant differences between groups at follow-up for three mental health outcomes: total SDQ, internalising problems, and prosocial behaviour. A small statistically significant difference in favour of the control group was found for externalising problems. Findings highlight the continued difficulties in developing effective, school-based prevention programs for mental health problems in adolescents.

TRIAL REGISTRATION

ANZCTR (Ref no: ACTRN12611000606987).

Association between adolescent tobacco, alcohol and illicit drug use and individual and environmental resilience protective factors

OBJECTIVES

Research suggests that individual and environmental resilience protective factors may be associated with adolescent substance use; however, the associations between a broad range of such factors and use of various types of substances have not been examined. The study aimed to determine the association between a comprehensive range of adolescent individual and environmental resilience protective factors and measures of tobacco, alcohol and illicit substance use.

DESIGN

Cross-sectional study.

SETTING

32 Australian secondary schools.

PARTICIPANTS

Grade 7-10 students (aged 11-17 years).

MEASURES

Data regarding 14 student individual and environmental resilience protective factors and seven substance use measures (tobacco, alcohol, marijuana, other illicit drug use) were obtained via an online self-report survey. Adjusted multivariate logistic regression analyses examined the association between all student resilience protective factors and seven substance use measures.

RESULTS

Inverse univariate associations were found for 94 of 98 relationships examined (n=10 092). Multivariate analyses found: consistent inverse associations between 2 of 14 protective factors and all substance use measures ('goals and aspirations', 'prosocial peers'); inverse associations between 4 protective factors with multiple substance use measures ('home support' (5 of 7), 'school support' (3 of 7), 'self-awareness' (2 of 7), 'community meaningful participation' (2 of 7)); positive associations between 2 resilience protective factors with multiple measures of substance use ('community support' (3 of 7), 'peer caring relationships' (5 of 7)) and 6 protective factors not to be associated with any substance use measure.

CONCLUSIONS

Despite individual relationships between the majority of resilience protective factors and substance use types, the protective benefit of such factors for adolescent substance use was limited to only a small number of such factors when considered collectively. Such results suggest that interventions seeking to reduce adolescent substance use may need to target specific protective factors to address specific types of substance use.

TRIAL REGISTRATION NUMBER

ACTRN12611000606987, Results.

Systematic review of universal resilience interventions targeting child and adolescent mental health in the school setting: review protocol

BACKGROUND

The mental health of children and adolescents is a key area of health concern internationally. Previous empirical studies suggest that resilience may act as a protective mechanism towards the development of mental health problems. Resilience refers to the ability to employ a collection of protective factors to return to or maintain positive mental health following disadvantage or adversity. Schools represent a potential setting within which protective factors of all children and adolescents may be fostered through resilience-focussed interventions. Despite this potential, limited research has investigated the effectiveness of universal school-based resilience-focussed interventions on mental health outcomes in children and adolescents. The objective of the present review is to assess the effects of universal school-based resilience-focussed interventions, relative to a comparison group, on mental health outcomes in children and adolescents.

METHODS/DESIGN

Eligible studies will be randomised (including cluster-randomised) controlled trials of universal interventions explicitly described as resilience-focussed or comprising strategies to strengthen a minimum of three internal protective factors, targeting children aged 5 to 18 years, implemented within schools, and reporting a mental health outcome. Screening for studies will be conducted across six electronic databases: MEDLINE, PsycINFO, Educational Resources Information Center (ERIC), Excerpta Medica database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL). Two reviewers will retrieve eligible articles, assess risk of bias, and extract data. Where studies are sufficiently homogenous and reported outcomes are amenable for pooled synthesis, meta-analysis will be performed. Narrative description will be used to synthesise trial outcome data where data cannot be combined or heterogeneity exists.

DISCUSSION

This review will aid in building an evidence base for the effectiveness of universal school-based resilience-focussed interventions and in doing so provide an opportunity to better inform the development of interventions to potentially prevent mental health problems in child and adolescent populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025908.