Targeted group-based interventions in schools to promote emotional well-being: a systematic review

Co-producing school-based mental health interventions with young people, teachers, and schools: a case study

BACKGROUND

Schools are a prime setting for the delivery of universal and targeted mental health interventions. Current school-based mental health interventions may not be developed to fully meet student mental health needs and co-production is needed to understand what young people really want. Despite this, research on school-based mental health interventions does not consistently engage in co-production, involving stakeholders, such as young people and schools, in the decision-making, development, evaluation and/or implementation stages. This highlights that transforming the development of school-based mental health interventions is crucial to meeting all stakeholders' needs. In this paper, we aim to briefly review an approach to co-production that can be used when conducting research on school-based mental health interventions that centre stakeholder voices to drive meaningful change. We describe a case study to showcase this approach.

MAIN BODY

We highlight recommendations and important elements to consider for each stakeholder when engaging in different levels of co-production, including young people, teachers, and schools. We provide practical examples of how this may look like in practice, theoretical underpinnings, and impact on outcomes. Our case study of co-producing a talk to improve mental health literacy in secondary school students is highlighted to demonstrate how a group of young people, teachers, epidemiologist, psychiatrist, and researchers can work together to develop school-based mental health interventions.

CONCLUSION

Co-production can be successfully conducted amongst researchers and stakeholders to develop school-based mental health interventions. Changes made to the talk were guided by synthesis of feedback that aligned with the balanced needs, perspectives, and opinions of all stakeholders. The use of this co-production approach in research on school-based mental health interventions with young people, teachers, and schools has important implications for research, service provision, and stakeholder empowerment.

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

The Social and Emotional Education and Development intervention to address wellbeing in primary school age children: the SEED cluster RCT

Background

Stronger social and emotional well-being during primary school is positively associated with the health and educational outcomes of young people. However, there is little evidence on which programmes are the most effective for improving social and emotional well-being.

Objective

The objective was to rigorously evaluate the Social and Emotional Education and Development (SEED) intervention process for improving pupils' social and emotional well-being.

Design

This was a stratified cluster randomised controlled trial with embedded process and economic evaluations. Thirty-eight primary schools were randomly assigned to the SEED intervention or to the control group. Hierarchical regression analysis allowing for clustering at school learning community level was conducted in R (statistical package).

Setting

The SEED intervention is a whole-school intervention; it involved all school staff and two cohorts of pupils, one starting at 4 or 5 years of age and the second starting at 8 or 9 years of age, across all 38 schools.

Participants

A total of 2639 pupils in Scotland.

Intervention

The SEED intervention used an iterative process that involved three components to facilitate selection and implementation of school-based actions: (1) questionnaire completion, (2) benchmarked feedback to all staff and (3) reflective discussions (all staff and an educational psychologist).

Main outcome measure

The primary outcome was pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score when pupils were 4 years older than at baseline.

Results

The primary outcome, pupils' Strengths and Difficulties Questionnaire-Total Difficulties Score at follow-up 3, showed improvements for intervention arm pupils, compared with those in the control arm [relative risk -1.30 (95% confidence interval -1.87 to -0.73), standardised effect size -0.27 (95% confidence interval -0.39 to -0.15)]. There was no evidence of intervention effects according to deprivation: the results were significant for both affluent and deprived pupils. Subgroup analysis showed that all effect sizes were larger for the older cohort, particularly boys [relative risk -2.36 (95% confidence interval -3.62 to -1.11), standardised effect size -0.42 (95% confidence interval -0.64 to -0.20)]. Although there was no statistically significant difference in incremental cost and quality-adjusted life-years, the probability that the intervention is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year was high, at 88%. Particularly valued mechanisms of the SEED intervention were its provision of time to reflect on and discuss social and emotional well-being and its contribution to a culture of evaluating practice.

Limitations

It was a challenge to retain schools over five waves of data collection.

Conclusions

This trial demonstrated that the SEED intervention is an acceptable, cost-effective way to modestly improve pupil well-being and improve school climate, particularly for older boys and those with greater levels of psychological difficulties. It was beneficial during the transition from primary to secondary school, but this diminished after 6 years. The SEED intervention can be implemented alongside existing systems for addressing pupil well-being and can be complementary to other interventions.

Future work

Assess whether or not the SEED intervention has a beneficial impact on academic attainment, is transferable to other countries and other organisational settings, would be strengthened by adding core training elements to the intervention process and is transferable to secondary schools. Understand the gender differences illustrated by the outcomes of this trial. Conduct further statistical research on how to handle missing data in longitudinal studies of complex social interventions.

Trial registration

This trial is registered as ISRCTN51707384.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 10/3006/13) and is published in full in Public Health Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Partnerships at the Interface of Education and Mental Health Services: The Utilisation and Acceptability of the Provision of Specialist Liaison and Teacher Skills Training

Partnerships between school staff and mental health professionals have the potential to improve access to mental health support for students, but uncertainty remains regarding whether and how they work in practice. We report on two pilot projects aimed at understanding the implementation drivers of tailored strategies for supporting and engaging front-line school staff in student mental health. The first project provided regular, accessible mental health professionals with whom school staff could meet and discuss individual or systemic mental health concerns (a school 'InReach' service), and the other offered a short skills training programme on commonly used psychotherapeutic techniques (the School Mental Health Toolbox; SMHT). The findings from the activity of 15 InReach workers over 3 years and 105 individuals who attended the SMHT training demonstrate that school staff made good use of these services. The InReach workers reported more than 1200 activities in schools (notably in providing specialist advice and support, especially for anxiety and emotional difficulties), whilst most SMHT training attendees reported the utilisation of the tools (in particular, supporting better sleep and relaxation techniques). The measures of acceptability and the possible impacts of the two services were also positive. These pilot studies suggest that investment into partnerships at the interface of education and mental health services can improve the availability of mental health support to students.

Linking Leeds: A Social Prescribing Service for Children and Young People

The use of social prescribing interventions for common mental health issues is expanding as clinicians seek to diverge from the traditional medical model of treatment. This intervention allows for the referral of patients to a nonclinical social activity via a link worker. Evidence for the benefits of social prescribing is growing. Most evidence is based on adults; however, a smaller number of studies involving children and young people have produced encouraging results. This evaluation reports on data routinely collected by the Linking Leeds service between 9 January 2019–11 January 2020. Linking Leeds provides Social Prescribing for people aged 16 years and above; however, the current paper focuses on service users aged between 16 and 25. Their aim is to connect people to services and activities in their community in order to benefit overall health and mental wellbeing. This evaluation of the Linking Leeds program supports the growing body of evidence to support the benefits social prescribing can have on young people’s mental health. Two main mechanisms were identified which underpin social prescribing in young people: social connectedness and behavioural activation.

Bounce Back: randomised trial of a brief, school-based group intervention for children with emergent mental health difficulties

We report the findings of the first randomised trial of Bounce Back, a brief, school-based group intervention for children with emergent mental health difficulties, whose aim is to improve their understanding of resilience and well-being, support them to build their confidence and friendships, and provide practical skills to make positive behaviour changes. 24 primary schools (N = 326 children) were randomly allocated to deliver the intervention or continue practice as usual in a waitlist design. Children in the intervention arm of the trial worked in groups of up to 15, supported by a trained youth practitioner, over ten weekly sessions that were delivered during the school day for up to an hour. Measures of emotional symptoms, behavioural difficulties, problem-solving, and self-esteem were recorded at baseline and post-intervention follow-up. Routinely collected session attendance data were used as a proxy for intervention compliance. Intent to treat analyses revealed that Bounce Back produced significant reductions in emotional symptoms (d = - 0.21). Furthermore, complier average causal effect analyses established that intervention compliance modified this treatment effect, such that children who attended more sessions accrued greater reductions in symptoms (moderate compliance d = - 0.54; high compliance d = - 0.61). There were no intervention effects for any of the other outcomes. Collectively, these findings provide robust preliminary evidence of the efficacy of Bounce Back.Trial registration: ISRCTN11162672.

School-Based Mental Health Promotion and Prevention Program "Turn 2 Us" Reduces Mental Health Risk Behaviors in Urban, Minority Youth

BACKGROUND

Turn 2 Us (T2U) is an elementary school-based mental health promotion and prevention program in New York City. It targets fourth- and fifth-grade students at risk for social/emotional and behavioral problems and provides a range of services to students, staff, and parents. The purpose of this study is to determine if T2U decreases internalizing and externalizing behaviors in participating students.

METHODS

Teachers measured students' symptoms before and after participation using the strengths and difficulties questionnaire (SDQ). Change in the total SDQ score was analyzed using Wilcoxon rank-sum nonparametric testing. We assessed the effects of covariates on the score change with linear regression models.

RESULTS

The 185 unique students who participated in the intervention showed a significant improvement in total SDQ score (Z = -4.107, p < .001). Students who were at higher risk prior to the intervention showed greatest improvement in behaviors. None of the covariates assessed affected the change in SDQ score. Regression models showed that higher initial SDQ scores predicted higher post-intervention SDQ scores (β = 0.681, p < .001).

CONCLUSION

T2U significantly decreased internalizing and externalizing behaviors in participating students, with the greatest impact for highest risk students. This study helps validate T2U's unique and comprehensive approach.

Delphi study to identify key features of community-based child and adolescent mental health services in the East of England

OBJECTIVE

To identify priorities for the delivery of community-based Child and Adolescent Mental health Services (CAMHS).

DESIGN

(1) Qualitative methods to gather public and professional opinions regarding the key principles and components of effective service delivery. (2) Two-round, two-panel adapted Delphi study. The Delphi method was adapted so professionals received additional feedback about the public panel scores. Descriptive statistics were computed. Items rated 8-10 on a scale of importance by ≥80% of both panels were identified as shared priorities.

SETTING

Eastern region of England.

PARTICIPANTS

(1) 53 members of the public; 95 professionals from the children's workforce. (2) Two panels. Public panel: round 1,n=23; round 2,n=16. Professional panel: round 1,n=44; round 2,n=33.

RESULTS

51 items met the criterion for between group consensus. Thematic grouping of these items revealed three key findings: the perceived importance of schools in mental health promotion and prevention of mental illness; an emphasis on how specialist mental health services are delivered rather than what is delivered (ie, specific treatments/programmes), and the need to monitor and evaluate service impact against shared outcomes that reflect well-being and function, in addition to the mere absence of mental health symptoms or disorders.

CONCLUSIONS

Areas of consensus represent shared priorities for service provision in the East of England. These findings help to operationalise high level plans for service transformation in line with the goals and needs of those using and working in the local system and may be particularly useful for identifying gaps in ongoing transformation efforts. More broadly, the method used here offers a blueprint that could be replicated by other areas to support the ongoing transformation of CAMHS.

Improving socio-emotional health for pupils in early secondary education with Pyramid: A school-based, early intervention model

BACKGROUND

Policymakers are focusing increased attention on the role of schools to promote and support children's mental health, and evidence-based models of good practice are in demand. Pyramid Club is a school-based, socio-emotional intervention, demonstrably effective with primary-aged pupils.

AIMS

This study extends previous Pyramid Club evaluations by examining effectiveness with pupils in early secondary education; service users' perceptions and experiences were investigated to increase understanding of Pyramid's impact, thus supporting enhanced practice.

SAMPLE

Participants (n = 126) comprised selected pupils, aged 11-14 (52 males; 74 females), who completed the 10 week programme (Pyramid group) and a non-intervention comparison group. Club leaders (n = 23) were trained, Pyramid volunteers.

METHODS

A mixed-methods design was implemented. The Strengths and Difficulties Questionnaire (SDQ), informant-rated version (Goodman, 1997, J Child Psychol Psychiat, 38, 581) and self-report version (Goodman, Meltzer, & Bailey, 1998, Europ Child Adolesc Psychiatry, 7, 125), was used to measure socio-emotional well-being: pre-club (baseline assessment), post-test (within 2 weeks of programme completion), and at 12-month follow-up (informant-rated version only). Focus groups were conducted separately with Pyramid pupils and Club leaders.

RESULTS

Findings from informants and self-reports identified significant improvements for the Pyramid group in total difficulties and on pertinent SDQ subscales (e.g., emotional symptoms and peer relationship problems) at post-test. Improvements were sustained at 12-month follow-up. Comparison pupils demonstrated minimal change over time. Thematic analysis of qualitative data supported the quantitative findings and provided valuable insights into the Pyramid Club experience.

CONCLUSIONS

Findings contribute to evidence-based, preventative models for the early adolescent population and support the social validity of Pyramid Club.

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.

Universal, school-based interventions to promote mental and emotional well-being: what is being done in the UK and does it work? A systematic review

OBJECTIVES

The present review aimed to assess the quality, content and evidence of efficacy of universally delivered (to all pupils aged 5-16 years), school-based, mental health interventions designed to promote mental health/well-being and resilience, using a validated outcome measure and provided within the UK in order to inform UK schools-based well-being implementation.

DESIGN

A systematic review of published literature set within UK mainstream school settings.

DATA SOURCES

Embase, CINAHL, MEDLINE, PsycINFO, PsychArticles, ASSIA and Psychological and Behavioural Sciences published between 2000 and April 2016.

ELIGIBILITY CRITERIA

Published in English; universal interventions that aimed to improve mental health/emotional well-being in a mainstream school environment; school pupils were the direct recipients of the intervention; pre-post design utilised allowing comparison using a validated outcome measure.

DATA EXTRACTION AND SYNTHESIS

12 studies were identified including RCTs and non-controlled pre-post designs (5 primary school based, 7 secondary school based). A narrative synthesis was applied with study quality check. 1 RESULTS: Effectiveness of school-based universal interventions was found to be neutral or small with more positive effects found for poorer quality studies and those based in primary schools (pupils aged 9-12 years). Studies varied widely in their use of measures and study design. Only four studies were rated 'excellent' quality. Methodological issues such as small sample size, varying course fidelity and lack of randomisation reduced overall study quality. Where there were several positive outcomes, effect sizes were small, and methodological issues rendered many results to be interpreted with caution. Overall, results suggested a trend whereby higher quality studies reported less positive effects. The only study that conducted a health economic analysis suggested the intervention was not cost-effective.

CONCLUSIONS

The current evidence suggests there are neutral to small effects of universal, school-based interventions in the UK that aim to promote emotional or mental well-being or the prevention of mental health difficulties. Robust, long-term methodologies need to be pursued ensuring adequate recording of fidelity, the use of validated measures sensitive to mechanisms of change, reporting of those lost to follow-up and any adverse effects. Further high-quality and large-scale research is required across the UK in order to robustly test any long-term benefits for pupils or on the wider educational or health system.

Youth mental ill health and secondary school completion in Australia: time to act

AIM

This paper reviews the evidence of youth mental ill health and its impact on secondary school educational attainment.

METHODS

This narrative review presents the current research related to the mental ill health of young people in urban and rural Australia, their educational attainment and the effectiveness of mental health strategies implemented in secondary schools.

RESULTS

The prevalence of mental ill health is high for Australian young people and the onset of depression, anxiety, substance-use disorders and first episode psychosis (FEP) commonly occurs when the individual is at school. The prevalence is reported to be higher for rural young people and barriers to treatment exist. Current evidence suggests that 40% of young people experiencing depression or anxiety disorders are not completing secondary school. Further evidence shows that over 50% of individuals who experience FEP do not finish secondary school. Current mental health promotion strategies employed in secondary schools have not been shown to reduce rates of depression or anxiety in adolescence nor identify prodromal or acute FEP. These strategies have not led to interventions that assist young people with mental ill health to finish school.

CONCLUSIONS

Not completing secondary school can limit employment options, lead to severe levels of disadvantage and increased burden on welfare and healthcare systems. All young people, including those in rural areas, have the right to education and should not be disadvantaged in their educational aspirations because they have an emerging or current mental illness.

Interventions for Adolescent Mental Health: An Overview of Systematic Reviews

Many mental health disorders emerge in late childhood and early adolescence and contribute to the burden of these disorders among young people and later in life. We systematically reviewed literature published up to December 2015 to identify systematic reviews on mental health interventions in adolescent population. A total of 38 systematic reviews were included. We classified the included reviews into the following categories for reporting the findings: school-based interventions (n = 12); community-based interventions (n = 6); digital platforms (n = 8); and individual-/family-based interventions (n = 12). Evidence from school-based interventions suggests that targeted group-based interventions and cognitive behavioral therapy are effective in reducing depressive symptoms (standard mean difference [SMD]: -.16; 95% confidence interval [CI]: -.26 to -.05) and anxiety (SMD: -.33; 95% CI: -.59 to -.06). School-based suicide prevention programs suggest that classroom-based didactic and experiential programs increase short-term knowledge of suicide (SMD: 1.51; 95% CI: .57-2.45) and knowledge of suicide prevention (SMD: .72; 95% CI: .36-1.07) with no evidence of an effect on suicide-related attitudes or behaviors. Community-based creative activities have some positive effect on behavioral changes, self-confidence, self-esteem, levels of knowledge, and physical activity. Evidence from digital platforms supports Internet-based prevention and treatment programs for anxiety and depression; however, more extensive and rigorous research is warranted to further establish the conditions. Among individual- and family-based interventions, interventions focusing on eating attitudes and behaviors show no impact on body mass index (SMD: -.10; 95% CI: -.45 to .25); Eating Attitude Test (SMD: .01; 95% CI: -.13 to .15); and bulimia (SMD: -.03; 95% CI: -.16 to .10). Exercise is found to be effective in improving self-esteem (SMD: .49; 95% CI: .16-.81) and reducing depression score (SMD: -.66; 95% CI: -1.25 to -.08) with no impact on anxiety scores. Cognitive behavioral therapy compared to waitlist is effective in reducing remission (odds ratio: 7.85; 95% CI: 5.31-11.6). Psychological therapy when compared to antidepressants have comparable effect on remission, dropouts, and depression symptoms. The studies evaluating mental health interventions among adolescents were reported to be very heterogeneous, statistically, in their populations, interventions, and outcomes; hence, meta-analysis could not be conducted in most of the included reviews. Future trials should also focus on standardized interventions and outcomes for synthesizing the exiting body of knowledge. There is a need to report differential effects for gender, age groups, socioeconomic status, and geographic settings since the impact of mental health interventions might vary according to various contextual factors.

The right location? Experiences of refugee adolescents seen by school-based mental health services

Access to needed mental health services can be particularly difficult for newly arrived refugee and asylum-seeking adolescents, although many attend school. This study examined young refugees' impressions and experience of mental health services integrated within the school system. Semi-structured interviews were conducted with 40 adolescent refugees discharged by three school-based mental health services across the United Kingdom. Two-thirds preferred to be seen at school. Rumination and worry about insecurity in the asylum process had a negative impact particularly on the adolescents' social functioning and ability to focus at school. The important role played by teachers in supporting and mediating contact with mental health services was valued by those interviewed. The study confirms that schools offer an important location for mental health services for adolescent refugees and provide an important portal for integration of services.

Mental health interventions in schools 1: Mental health interventions in schools in high-income countries

Mental health services embedded within school systems can create a continuum of integrative care that improves both mental health and educational attainment for children. To strengthen this continuum, and for optimum child development, a reconfiguration of education and mental health systems to aid implementation of evidence-based practice might be needed. Integrative strategies that combine classroom-level and student-level interventions have much potential. A robust research agenda is needed that focuses on system-level implementation and maintenance of interventions over time. Both ethical and scientific justifications exist for integration of mental health and education: integration democratises access to services and, if coupled with use of evidence-based practices, can promote the healthy development of children.