Reducing child conduct problems and promoting social skills in a middle-income country: cluster randomised controlled trial

Implementation in the "real world" of an evidence-based social and emotional learning program for teachers: effects on children social, emotional, behavioral and problem solving skills

Introduction

The delivery of social and emotional learning (SEL) programs that are developmentally school-based and evidence-based has the potential to benefit many children, and as such, greater efforts are needed to disseminate these programs more widely within the community. The Incredible Years® Teacher Classroom Management (IY-TCM) has shown promising results when applied by teachers in preschool centers and primary schools, as seen in several randomized control trials conducted worldwide, including in Portugal.

Methods

The current study presents a model of the implementation of the program within the framework of a nationwide initiative undertaken in Portugal: the Academias Gulbenkian do Conhecimento. Additionally, results of the program's impact on children were explored using ANOVA, which compared pre- to post- treatment outcomes. To assess which factors affected the efficacy of the intervention, moderation analyses were conducted using the MEMORE macro. Ninety teachers and 535 children (2 to 10 years old) were assessed.

Results

Results revealed that children showed significant increases in social and emotional skills (e.g., social adjustment, empathy) and significant reductions in problem behavior when assessed by their teachers, and in social-cognitive problem solving strategies as evaluated by a set of problem-solving tasks. Moderation analyses showed that, in general, interaction effects were not found, meaning that the intervention was effective for almost all conditions. Nevertheless, significant moderation effects were found for factors pertaining to the child and the mother with respect to pro-social and emotional skills (children who benefited most from the intervention exhibited more behavioral difficulties at the baseline according to the teachers' perceptions and had mothers without a university degree; children attending primary school took less benefit from the intervention than those attending pre-school).

Discussion

The findings contribute both to the reinforcement of the effectiveness of the IY-TCM program as a universal intervention in "real world" schools and to the development of some guidelines for the promotion of effective scaling up and sustainability of program effects.

The Process of Scaling Early Childhood Violence Prevention Programs in Jamaica

BACKGROUND

Violence is a global public health problem, and early childhood interventions are a core component of violence prevention programming. Interventions to support parents and teachers of young children can prevent violence against children by caregivers and prevent the early development of antisocial behavior. However, there is limited guidance on how to scale up these programs in low- and middle-income countries.

METHODS

In this article, we describe how we applied implementation science principles in the design, implementation, evaluation, and initial scaling of 2 complementary early childhood, violence prevention, caregiver training programs in Jamaica: the Irie Classroom Toolbox (a teacher-training program) and the Irie Homes Toolbox (a parenting program).

RESULTS

We identified 7 implementation science principles most relevant to our work in scaling the Irie Toolbox programs and describe how these principles were operationalized in the Jamaican context. The principles are: (1) design programs for scale from the outset; (2) use learning cycles for quality improvement; (3) plan strategically for government agency adoption; (4) provide high-quality initial and ongoing training and regular supervision; (5) monitor implementation quality; (6) use flexible delivery modes; and (7) plan for program sustainment.

CONCLUSIONS

Through applying these principles to scale the Irie Toolbox programs, we aim to promote a consistent approach to reducing violence against children, reducing child behavior problems, and increasing caregiver and child competencies across both home and school contexts at the population level. The principles and processes described in this article are relevant to other behavior change interventions in early childhood development, education, and public health.

Factors associated with children and young people's mental health in the English-speaking Caribbean region: Systematic review and narrative synthesis

BACKGROUND

Studies conducted in regions consisting of low and middle income and developing countries often report high prevalence of mental health problems among children and young people (CYP). To identify some of the contributing factors we examined the available evidence from research in one such setting.

METHODS

Multiple academic databases and grey literature sources were searched until January 2022. We then identified primary research focusing on CYP's mental health in the English-speaking Caribbean region. Data was extracted and summarized to form a narrative synthesis of the factors associated with CYP's mental health. The synthesis was then organised according to the social-ecological model. The Joanna Briggs Institute's critical appraisal tools were used to examine the quality of the reviewed evidence. The study protocol was registered with PROSPERO, CRD42021283161.

RESULTS

From 9684 records, 83 publications representing CYP ages 3 to 24 years from 13 countries met our inclusion criteria. The evidence was varied in quality, quantity and consistency for 21 factors associated with CYP's mental health. Adverse events and negative peer to peer and sibling relationships were consistently associated with mental health problems, while helpful coping strategies were associated with better mental health. There were mixed findings for age, sex/gender, race/ethnicity, academic level, comorbidity, positive affect, health risks behaviours, religion/prayer, parent history, parent to parent and parent to child relationships, school/employment, geography and social status. There was also some limited evidence for associations between sexuality, screen time and policies/procedures and CYP's mental health. At least 40% of the evidence contributing to each of the factors was judged as high quality.

CONCLUSION

Individual, relationship, community and societal factors may influence CYP's mental health outcomes in the English-speaking Caribbean. Knowledge of these factors is useful to inform early identification and early interventions. More research is needed to explore inconsistent findings and understudied areas.

A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries

BACKGROUND

Treatments for mental health problems in childhood and adolescence have advanced in the last 15 years. Despite advances in research, most of the evidence on effective interventions comes from high-income countries, while evidence is scarce in low- and middle-income countries (LMICs), where 90% of world's children and adolescents live. The aim of this review was to identify evidence-based interventions tested in LMICs to treat or prevent child and adolescent mental health problems.

METHODS

We conducted a systematic review of seven major electronic databases, from January 2007 to July 2019. We included randomised or non-randomised clinical trials that evaluated interventions for children or adolescents aged 6 to 18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems. Results were grouped according to the studied conditions. Due to the heterogeneity of conditions, interventions and outcomes, we performed a narrative synthesis. The review was registered at PROSPERO under the number CRD42019129376.

FINDINGS

Of 127,466 references found through our search strategy, 107 studies were included in narrative synthesis after the eligibility verification processes. Nineteen different conditions and nine types of interventions were addressed by studies included in the review. Over 1/3 of studied interventions were superior to comparators, with psychoeducation and psychotherapy having the highest proportion of positive results. One-third of studies were classified as presenting low risk of bias.

INTERPRETATION

This review shows that different interventions have been effective in LMICs and have the potential to close the mental health care gap among children and adolescents in low-resource settings.

Systematic Review and Meta-Analysis of the Effectiveness of Teacher Delivered Interventions for Externalizing Behaviors

This systematic review and meta-analysis explores the effectiveness of teacher interventions supporting children with externalizing behaviors based on teacher and child outcomes. A systematic search was conducted using 5 electronic databases. From 5714 papers, 31 papers that included interventions delivered directly to teachers and aimed to benefit either teachers and/or children with externalizing behaviors were included. The review focused on qualified teachers working with children aged 2-13. The results of the current meta-analysis revealed a positive effect of teacher intervention on teacher and child outcomes, including the increased use of teacher-appropriate strategies, as well as significant and moderate improvements in teacher-child closeness, and small reductions in teacher-child conflict. For child outcomes, the interventions reduced externalizing behavior problems and ADHD symptoms and enhanced prosocial behavior. Only one fully blinded analysis for conduct problems was possible and revealed a moderate but significant reduction in favor of intervention. These findings provide evidence to support the role of teacher interventions for both teachers and children with externalizing behaviors. Future research should include more PBLIND measurements so that MPROX findings can be confirmed. More research should be done to evaluate the influence of teacher interventions on teachers' well-being.

Advancing scalability and impacts of a teacher training program for promoting child mental health in Ugandan primary schools: protocol for a hybrid-type II effectiveness-implementation cluster randomized trial

BACKGROUND

Children in low-and-middle-income countries (LMICs) are facing tremendous mental health challenges. Numerous evidence-based interventions (EBIs) have been adapted to LMICs and shown effectiveness in addressing the needs, but most EBIs have not been adopted widely using scalable and sustainable implementation models that leverage and strengthen existing structures. There is a need to apply implementation science methodology to study strategies to effectively scale-up EBIs and sustain the practices in LMICs. Through a cross-sector collaboration, we are carrying out a second-generation investigation of implementation and effectiveness of a school-based mental health EBI, ParentCorps Professional Development (PD), to scale-up and sustain the EBI in Uganda to promote early childhood students' mental health. Our previous studies in Uganda supported that culturally adapted PD resulted in short-term benefits for classrooms, children, and families. However, our previous implementation of PD was relied on mental health professionals (MHPs) to provide PD to teachers. Because of the shortage of MHPs in Uganda, a new scalable implementation model is needed to provide PD at scale.

OBJECTIVES

This study tests a new scalable and sustainable PD implementation model and simultaneously studies the effectiveness. This paper describes use of collaboration, task-shifting, and Train-the-Trainer strategies for scaling-up PD, and protocol for studying the effectiveness-implementation of ParentCorps-PD for teachers in urban and rural Ugandan schools. We will examine whether the new scale-up implementation approach will yield anticipated impacts and investigate the underlying effectiveness-implementation mechanisms that contribute to success. In addition, considering the effects of PD on teachers and students will influence by teacher wellness. This study also examines the added value (i.e. impact and costs) of a brief wellness intervention for teachers and students.

METHODS

Using a hybrid-type II effectiveness-implementation cluster randomized controlled trial (cRCT), we will randomize 36 schools (18 urban and 18 rural) with 540 teachers and nearly 2000 families to one of three conditions: PD + Teacher-Wellness (PDT), PD alone (PD), and Control. Primary effectiveness outcomes are teachers' use of mental health promoting strategies, teacher stress management, and child mental health. The implementation fidelity/quality for the scale-up model will be monitored. Mixed methods will be employed to examine underlying mechanisms of implementation and impact as well as cost-effectiveness.

DISCUSSION

This research will generate important knowledge regarding the value of an EBI in urban and rural communities in a LMIC, and efforts toward supporting teachers to prevent and manage early signs of children's mental health issues as a potentially cost-effective strategy to promote child population mental health in low resource settings.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (registration number: NCT04383327; https://clinicaltrials.gov/ct2/show/NCT04383327 ) on May13, 2020.

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

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

Children and young people's mental health in the English-speaking Caribbean: a scoping review and evidence map

Internationally, there is a wealth of research suggesting that many children and young people experience mental health problems. However, the evidence from low- and middle-income countries and developing nations is generally limited. This scoping review aimed to add to the body of evidence by providing an overview of the available research literature on children and young people's (CYP's) mental health in the English-speaking Caribbean region. Seven key online academic databases and grey literature sources were searched until January 2021. Records were screened against predefined criteria and suitable articles retrieved. Relevant information was then charted and summarized. All stages of the review were informed by expert consultations. Ninety-six articles from 7901 records met the inclusion criteria. Most of the studies were conducted in Jamaica, Trinidad and Tobago and Barbados while fewer studies reported findings from St Lucia, The Bahamas and St Kitts and Nevis. Research funding was not frequently reported, and participants were predominantly recruited in education settings. There was a substantial focus on depressive symptoms and behaviour problems. Little or no research was available for younger children (< 12), complex clinical cases or commonly under-represented groups. Four unique interventions were identified of which one intervention showed no significant impact on CYP. Among the commonly used outcome measures only the Jamaican Youth Checklist (teacher-reported), Beck Depression Inventory-II, Brief Screen for Depression, Trinidad and Tobago Youth Survey and Minnesota Multiphasic Personality Inventory had evidence for psychometric validity within this population. We discuss future directions, implications and recommendations for research, practice, policy and training.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Effects of a Teacher-Training Violence Prevention Program in Jamaican Preschools on Child Behavior, Academic Achievement, and School Attendance in Grade One of Primary School: Follow up of a Cluster Randomized Trial

Objective: We evaluated the effect of a universal, teacher-training, violence-prevention program implemented in preschool, on high-risk children's behavior, achievement, and attendance in grade one of primary school. Methods: A cluster-randomized trial was conducted in 24 preschools in Kingston, Jamaica. Three children from each class with the highest level of teacher-reported conduct problems were recruited for evaluation of outcomes (n = 225 children). For this study, to increase power, we recruited an additional two children from each class with the next highest teacher-reported scores for conduct problems in preschool. In the final term of grade one of primary school, we assessed children's: (1) conduct problems and social skills at home and school, (2) academic achievement, language, and self-regulation skills, and (3) school attendance. Results: 214/225 (95.1%) of the children evaluated in preschool were assessed in grade one of primary school; an additional 150 children were recruited to give 364 children (181 intervention, 183 control). Significant benefits of intervention were found for child academic achievement (Effect size (ES) = 0.23, p = 0.02), oral language (ES = 0.28, p = 0.006), self-regulation (ES = 0.25, p = 0.007), and school attendance (ES = 0.30, p = 0.003). No significant benefits were found for observed conduct problems (ES = -0.13, p = 0.16), and parent-reported conduct problems (ES = 0.10, p = 0.31) and social skills (ES = -0.07, p = 0.52). Benefits to teacher-reported conduct problems and social skills were significant at p < 0.1 (ES = -0.16, p = 0.09, and ES = 0.19, p = 0.06, respectively). Conclusion: A scalable intervention involving training preschool teachers in classroom behavior management and how to promote child social-emotional competence led to positive outcomes in primary school across multiple child developmental domains for high-risk children.

Um Compasso Para Aprender: A Randomized Trial of a Social-Emotional Learning Program in Homicide-Affected Communities in Brazil

Despite global demand, the large-scale effects of social-emotional learning (SEL) programming in developing countries remain underexplored. Using a randomized control trial, this study examined the effectiveness of a school-wide SEL intervention-Programa Compasso (PC)-among 3,018 sociodemographically diverse, Portuguese-speaking children (M_age  = 9.85 years) attending 90 public primary schools across Rio de Janeiro, Brazil in 2017. Average impacts of PC on children's executive function, emotion knowledge, and behavior problems after one school year were null. Moderation analyses did, however, reveal evidence for positive impacts of PC on children's labeling of emotional expressions and inhibitory control within low-homicide communities (d = 0.15 SDs), and null effects on these same outcomes in high-violence areas. Implementation and cultural considerations are discussed.

The Irie Classroom Toolbox, a universal violence-prevention teacher-training programme, in Jamaican preschools: a single-blind, cluster-randomised controlled trial

BACKGROUND

Violence is a leading global public health problem, and interventions in early childhood are important in the primary prevention of violence. We tested whether the Irie Classroom Toolbox, a violence-prevention teacher-training programme reduced violence against children by teachers and reduced class-wide child aggression in Jamaican preschools (catering to children aged 3-6 years).

METHODS

We did a single-blind, cluster-randomised controlled trial in 76 preschools in Kingston and St Andrew, randomly selected, using simple randomisation, from 120 eligible preschools. Inclusion criteria were two to four classes of children; at least ten children per class; and located in an urban area. We randomly assigned preschools (1:1) to either the Irie Classroom Toolbox intervention or waiting-list control that received no intervention, using a computer-generated randomisation sequence by an independent statistician masked to school identity. The Toolbox involved training teachers in classroom behaviour management and promoting child social-emotional competence. All assessors were masked to group assignment. All teachers and classrooms in the selected schools participated in the study. Within each school, we used simple randomisation to randomly select up to 12 children aged 4 years for evaluation of child outcomes. The Toolbox intervention was implemented from August to April the following year. Teacher and classroom measures were done at baseline (the summer school term; ie, May to June), post-intervention (after 8 months of intervention; ie, May to June of the following year), and 1-year follow-up (ie, May to June 2 years later). The primary outcomes were observations of violence against children (including physical violence and psychological aggression) by teachers occurring across one full school day, and class-wide child aggression occurring over five 20-min intervals on another school day, all measured at post-intervention and 1-year follow-up and analysed by intention to treat. This trial is registered with ISRCTN, number ISRCTN11968472.

FINDINGS

Between June 22, 2015, and April 29, 2016, (after baseline measurements were completed), we assigned 38 preschools (with 119 teachers) to the Toolbox intervention and 38 preschools (with 110 teachers) to control. 441 children in the intervention schools and 424 in the control schools were included in the evaluation. All schools were included in the post-intervention and follow-up analyses. There were fewer counts of violence against children by teachers in the intervention schools compared with control schools at post-intervention (median counts 3 [IQR 0-11] vs 15 [3-35]; effect size -67·12%, 95% CI -80·71 to -53·52, p<0·0001) and 1-year follow-up (median counts 3 [IQR 0-9] vs 6 [1-16]; effect size -53·86, 95% CI -71·08 to -36·65, p<0·0001). No differences between groups were found for class-wide child aggression at post-intervention (effect size 0·07, 95% CI -0·16 to 0·29, p=0·72) or 1-year follow-up (-0·14, -0·42 to 0·16, p=0·72).

INTERPRETATION

In Jamaican preschools, the Irie Classroom Toolbox effectively reduced violence against children by teachers. The Toolbox was designed for use with undertrained teachers working in low-resource settings and should be effective with early childhood practitioners in other LMICs. Additional research is needed to further develop the Toolbox to reduce class-wide child aggression.

FUNDING

Medical Research Council, Wellcome Trust, UK Aid, and the National Institute of Health Research.

Does the Incredible Years Teacher Classroom Management programme improve child-teacher relationships in childcare centres? A 1-year universal intervention in a Norwegian community sample

The Incredible Years Teacher Classroom Management (IY TCM) programme has shown promise in reducing behaviour problems among high-risk children in childcare. However, at present, we do not know whether the IY TCM successfully improves the child-teacher relationship in childcare and whether the effects manifest in both the population and in high-risk groups. Hence, we conducted a quasi-experimental pre-post study with a matched control condition to examine the changes in child-teacher relationships in a sample of 1085 children aged 3-6 years after implementing the IY TCM programme. Linear mixed models revealed favourable group-by-time differences benefitting the intervention compared to the control condition. Subgroup analyses of children scoring at or above the 90th percentile on either internalising or externalising behaviour problems showed that the preventive effects persisted in both high-risk subsamples. In sum, the findings indicate that the IY TCM programme does improve child-teacher relationships and that the effect is present for the entire study population as well as children scoring in the clinical range on behaviour problems. This suggests that the application of the IY TCM programme in childcare settings has important preventive effects. Implications and limitations are further discussed.

Preventing violence against children in schools (PVACS): protocol for a cluster randomised controlled trial of the EmpaTeach behavioural intervention in Nyarugusu refugee camp

BACKGROUND

We aim to test the effectiveness of the EmpaTeach intervention to prevent physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. EmpaTeach is a 10-week, 14-session, classroom management and cognitive-behavioural therapy-based intervention for groups of teachers for delivery by lay personnel in resource-constrained settings.

METHODS

We will conduct a two-arm cluster randomized controlled trial (RCT) with parallel assignment and an approximately 1:1 allocation ratio. All primary and secondary schools in Nyarugusu will be invited to participate. Whole schools will be stratified according to whether they are Congolese or Burundian, and primary or secondary schools, then randomised to active intervention or wait-list control conditions via a public meeting with headteachers. We will collect survey data from n = 500 teachers and at least n = 1500 students before the intervention, soon after, and at least 6 months after the end of the intervention. The primary outcome measure will be students' self-reports of experience of physical violence from school staff in the past week, measured using a modified version of the International Society for the Prevention of Child Abuse and Neglect Screening Tool-Child Institutional at the first follow-up after the intervention. Secondary outcomes include emotional violence, depressive symptoms and educational test scores. Analysis will be intention to treat, using repeat cross-sectional data from individuals.

DISCUSSION

If successful, the EmpaTeach intervention would represent one of a handful of proven interventions to reduce violence from teachers to students in any setting. IRC provides an immediate platform for scale up of the intervention via its current work in more than 40 conflict-affected countries.

TRIAL REGISTRATION

NCT03745573 , registered November 19, 2018 at clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03745573 .

Evaluation of a Violence-Prevention Programme with Jamaican Primary School Teachers: A Cluster Randomised Trial

This study investigated the effect of a school-based violence prevention programme implemented in Grade 1 classrooms in Jamaican primary schools. Fourteen primary schools were randomly assigned to receive training in classroom behaviour management (n = 7 schools, 27 teachers/classrooms) or to a control group (n = 7 schools, 28 teachers/classrooms). Four children from each class were randomly selected to participate in the evaluation (n = 220 children). Teachers were trained through a combination of workshop and in-class support sessions, and received a mean of 11.5 h of training (range = 3–20) over 8 months. The primary outcomes were observations of (1) teachers’ use of violence against children and (2) class-wide child aggression. Teachers in intervention schools used significantly less violence against children (effect size (ES) = −0.73); benefits to class-wide child aggression were not significant (ES = −0.20). Intervention teachers also provided a more emotionally supportive classroom environment (ES = 1.22). No benefits were found to class-wide prosocial behaviour, teacher wellbeing, or child mental health. The intervention benefited children’s early learning skills, especially oral language and self-regulation skills (ES = 0.25), although no benefits were found to achievement in maths calculation, reading and spelling. A relatively brief teacher-training programme reduced violence against children by teachers and increased the quality of the classroom environment.

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

BACKGROUND

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

METHODS

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

TRIAL REGISTRATION

ISRCTN84130388.

RESULTS

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

CONCLUSIONS

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

A systematic review of tools used to screen and assess for externalising behaviour symptoms in low and middle income settings

BACKGROUND

Mental health issues, often manifested as behavioural difficulties, in children are estimated to be high in low and middle-income countries (LMIC) settings. There is a paucity of definitive data due to a lack of well-validated tools to use across settings. This review aims to provide evidence on what tools are used and which have been adapted and validated in LMIC settings.

METHODS

We performed a systematic review to identify tools used to assess or screen externalising behaviour problems in children and adolescents in LMIC and assess their cultural adaptations. We searched for studies measuring externalising behaviour in children from 0 to 19 years published up to September 2018. Articles were assessed to identify tools used and analysed using the Ecological Validity Framework.

RESULTS

We identified 82 articles from over 50 LMICs who had studied externalising behaviour in children. Twenty-seven tools were identified, with a predominance of studies using tools from the USA and Europe. Most studies did not describe an adaptation and evaluation process, with only one study following recommended criteria. New tools were identified which both screen and assess externalising behaviour which have not yet been utilised across settings.

CONCLUSIONS

Although tools from the USA and Europe are often utilised to screen and assess for externalising behaviour problems in children in LMICs, the conceptual frameworks behind the use of these tools in other cultural contexts are not always carefully examined. In order to have valid data across cultures, we should aim to adapt and validate tools before use. Provision of processes to validate tools across LMIC settings would be beneficial.

Parents' use of harsh punishment and young children's behaviour and achievement: a longitudinal study of Jamaican children with conduct problems

INTRODUCTION

Harsh punishment by parents is common in low- and middle-income countries (LMIC), yet there is limited evidence from LMIC of the effects of harsh punishment on child outcomes.

METHODS

A longitudinal, prospective study was conducted with children with conduct problems to examine the associations between parents' use of harsh punishment during the preschool years on child behaviour and school achievement in grade one of primary school. As part of an efficacy trial in 24 preschools, 225 children with the highest level of teacher-reported conduct problems were evaluated and their parents reported on how often they used harsh punishment. Outcome measures in grade one included child conduct problems by independent observation, teacher and parent report, child social skills by teacher and parent report, direct tests of children's academic achievement and language skills, and tester ratings of child attention and impulse control.

RESULTS

Children had a mean age of 6.92 years and 61% were boys. All parents reported using harsh punishment. After controlling for child age and sex, socio-economic status, parents' involvement with child and maternal education, frequency of harsh punishment was associated with growth in child conduct problems by independent classroom observations (p  =  0.037), parent (p  =  0.018) and teacher (p  =  0.044) report, a reduction in child social skills by teacher (p  =  0.024) and parent (p  =  0.014) report and poorer attention during the test session (p  =  0.049).

CONCLUSION

The associations between frequency of parents' use of harsh punishment with their preschoolers with conduct problems and later child behaviour indicate a need to train parents in non-violent behaviour management.

Psychosocial interventions for disruptive behaviour problems in children in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Most of the evidence for psychosocial interventions for disruptive behaviour problems comes from Western, high-income countries. The transferability of this evidence to culturally diverse, low-resource settings with few mental health specialists is unknown.

METHODS

We conducted a systematic review with random-effects meta-analysis of randomized controlled trials examining the effects of psychosocial interventions on reducing behaviour problems among children (under 18) living in low- and middle-income countries (LMIC).

RESULTS

Twenty-six randomized controlled trials (representing 28 psychosocial interventions), evaluating 4,441 subjects, met selection criteria. Fifteen (54%) prevention interventions targeted general or at-risk populations, whereas 13 (46%) treatment interventions targeted children selected for elevated behaviour problems. Most interventions were delivered in group settings (96%) and half (50%) were administered by non-specialist providers. The overall effect (standardized mean difference, SMD) of prevention studies was -0.25 (95% confidence interval (CI): -0.41 to -0.09; I² : 78%) and of treatment studies was -0.56 (95% CI: -0.51 to -0.24; I² : 74%). Subgroup analyses demonstrated effectiveness for child-focused (SMD: -0.35; 95% CI: -0.57 to -0.14) and behavioural parenting interventions (SMD: -0.43; 95% CI: -0.66 to -0.20), and that interventions were effective across age ranges.

CONCLUSIONS

Our meta-analysis supports the use of psychosocial interventions as a feasible and effective way to reduce disruptive behaviour problems among children in LMIC. Our study provides strong evidence for child-focused and behavioural parenting interventions, interventions across age ranges and interventions delivered in groups. Additional research is needed on training and supervision of non-specialists and on implementation of effective interventions in LMIC settings.

Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review

BACKGROUND

Cluster randomised trials (CRTs) are a key instrument to evaluate public health interventions. Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity (IF) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions conducted in low- and middle-income countries (LMICs). However, current CRT reporting guidelines offer no guidance on IF assessment. The objective of this review was to study current practices concerning the assessment of IF in CRTs of public health interventions in LMICs.

METHODS

CRTs of public health interventions in LMICs that planned or reported IF assessment in either the trial protocol or the main trial report were included. The MEDLINE/PubMed, CINAHL and EMBASE databases were queried from January 2012 to May 2016. To ensure availability of a study protocol, CRTs reporting a registration number in the abstract were included. Relevant data were extracted from each study protocol and trial report by two researchers using a predefined screening sheet. Risk of bias for individual studies was assessed.

RESULTS

We identified 90 CRTs of public health interventions in LMICs with a study protocol in a publicly available trial registry published from January 2012 to May 2016. Among these 90 studies, 25 (28%) did not plan or report assessing IF; the remaining 65 studies (72%) addressed at least one IF dimension. IF assessment was planned in 40% (36/90) of trial protocols and reported in 71.1% (64/90) of trial reports. The proportion of overall agreement between the trial protocol and trial report concerning occurrence of IF assessment was 66.7% (60/90). Most studies had low to moderate risk of bias.

CONCLUSIONS

IF assessment is not currently a systematic practice in CRTs of public health interventions carried out in LMICs. In the absence of IF assessment, it may be difficult to determine if CRT results are due to the intervention design, to its implementation, or to unknown or external factors that may influence results. CRT reporting guidelines should promote IF assessment.

TRIAL REGISTRATION

Protocol published and available at: https://doi.org/10.1186/s13643-016-0351-0.

From Community to Meta-Community Mental Health Care

Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although community mental health care has been positive for many service users, it has also had severe shortcomings. Expectations that it would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered or custodial environments with limited social contacts and no prospect of work. Others receive little or no service at all. In today’s complex landscape of increasingly specialised services for people with mental health problems, the number of possible interfaces between services is increasing. Together with existing uneven financing systems and a context of constant change, these interfaces are challenging us to develop effective care pathways adjusted to the needs of service users and their carers. This discussion paper reviews the developments in community mental health care over the recent years and puts forward the concept of “Meta-Community Mental Health Care”. “Meta-Community Mental Health Care” embraces pluralism in understanding and treating psychiatric disorders, acknowledges the complexities of community provision, and reflects the realities and needs of the current era of care.

Feasibility study of a family- and school-based intervention for child behavior problems in Nepal

BACKGROUND

This study evaluates the feasibility, acceptability, and outcomes of a combined school- and family-based intervention, delivered by psychosocial counselors, for children with behavior problems in rural Nepal.

METHODS

Forty-one children participated at baseline. Two students moved to another district, meaning 39 children, ages 6-15, participated at both baseline and follow-up. Pre-post evaluation was used to assess behavioral changes over a 4-month follow-up period (n = 39). The primary outcome measure was the Disruptive Behavior International Scale-Nepal version (DBIS-N). The secondary outcome scales included the Child Functional Impairment Scale and the Eyberg Child Behavior Inventory (ECBI). Twelve key informant interviews were conducted with community stakeholders, including teachers, parents, and community members, to assess stakeholders' perceptions of the intervention.

RESULTS

The study found that children's behavior problems as assessed on the DBIS-N were significantly lower at follow-up (M = 13.0, SD = 6.4) than at baseline (M = 20.5, SD = 3.8), p < 0.001, CI [5.57, 9.35]. Similarly, children's ECBI Intensity scores were significantly lower at follow-up (M = 9.9, SD = 8.5) than at baseline (M = 14.8, SD = 7.7), p < 0.005, 95% CI [1.76, 8.14]. The intervention also significantly improved children's daily functioning. Parents and teachers involved in the intervention found it acceptable and feasible for delivery to their children and students. Parents and teachers reported improved behaviors among children and the implementation of new behavior management techniques both at home and in the classroom.

CONCLUSIONS

Significant change in child outcome measures in this uncontrolled evaluation, alongside qualitative findings suggesting feasibility and acceptability, support moving toward a controlled trial to determine effectiveness.

Who perpetrates violence against children? A systematic analysis of age-specific and sex-specific data

OBJECTIVE

The epidemiology of violence against children is likely to differ substantially by sex and age of the victim and the perpetrator. Thus far, investment in effective prevention strategies has been hindered by lack of clarity in the burden of childhood violence across these dimensions. We produced the first age-specific and sex-specific prevalence estimates by perpetrator type for physical, sexual and emotional violence against children globally.

DESIGN

We used random effects meta-regression to estimate prevalence. Estimates were adjusted for relevant quality covariates, variation in definitions of violence and weighted by region-specific, age-specific and sex-specific population data to ensure estimates reflect country population structures.

DATA SOURCES

Secondary data from 600 population or school-based representative datasets and 43 publications obtained via systematic literature review, representing 13 830 estimates from 171 countries.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Estimates for recent violence against children aged 0-19 were included.

RESULTS

The most common perpetrators of physical and emotional violence for both boys and girls across a range of ages are household members, with prevalence often surpassing 50%, followed by student peers. Children reported experiencing more emotional than physical violence from both household members and students. The most common perpetrators of sexual violence against girls aged 15-19 years are intimate partners; however, few data on other perpetrators of sexual violence against children are systematically collected internationally. Few age-specific and sex-specific data are available on violence perpetration by schoolteachers; however, existing data indicate high prevalence of physical violence from teachers towards students. Data from other authority figures, strangers, siblings and other adults are limited, as are data on neglect of children.

CONCLUSIONS

Without further investment in data generation on violence exposure from multiple perpetrators for boys and girls of all ages, progress towards Sustainable Development Goals 4, 5 and 16 may be slow. Despite data gaps, evidence shows violence from household members, peers in school and for girls, from intimate partners, should be prioritised for prevention.

TRIAL REGISTRATION NUMBER

PROSPERO 2015: CRD42015024315.

Effect of transporting an evidence-based, violence prevention intervention to Jamaican preschools on teacher and class-wide child behaviour: a cluster randomised trial

INTRODUCTION

Based on extensive piloting work, we adapted the Incredible Years (IY) teacher-training programme to the Jamaican preschool setting and evaluated this adapted version through a cluster-randomised trial.

METHODS

Twenty-four community preschools in Kingston, Jamaica were randomly assigned to intervention (12 schools, 37 teachers) or control (12 schools, 36 teachers). The intervention involved training teachers in classroom management through eight full-day training workshops and four individual 1-h in-class support sessions. Outcome measurements included direct observation of teachers' positive and negative behaviours to the whole class and to high-risk children and four observer ratings: two measures of class-wide child behaviour and two measures of classroom atmosphere. Measures were repeated at a six-month follow-up.

RESULTS

Significant benefits of intervention were found for teachers' positive [effect size (ES) = 3.35] and negative (ES = 1.29) behaviours to the whole class and to high-risk children (positive: ES = 0.83; negative: ES = 0.50) and for observer ratings of class-wide child behaviour (ES = 0.73), child interest and enthusiasm (ES = 0.98), teacher warmth (ES = 2.03) and opportunities provided to share and help (ES = 5.72). At 6-month follow-up, significant benefits of intervention were sustained: positive behaviours (ES = 2.70), negative behaviours (ES = 0.98), child behaviour (ES = 0.50), child interest and enthusiasm (ES = 0.78), teacher warmth (ES = 0.91), opportunities to share and help (ES = 1.42).

CONCLUSIONS

The adapted IY teacher-training programme produced large benefits to teacher's behaviour and to class-wide measures of children's behaviour, which were sustained at 6-month follow-up. Benefits were of a similar magnitude to those found in a pilot study of the minimally adapted version that required significantly more in-class support for teachers.

Evidence Base Update for Psychosocial Treatments for Disruptive Behaviors in Children

This article reviews the state of the science on psychosocial treatments for disruptive behaviors in children, as an update to Eyberg, Nelson, and Boggs (2008). We followed procedures for literature searching, study inclusion, and treatment classification as laid out in Southam-Gerow and Prinstein (2014), focusing on treatments for children 12 years of age and younger. Two treatments (group parent behavior therapy, and individual parent behavior therapy with child participation) had sufficient empirical support to be classified as well-established treatments. Thirteen other treatments were classified as probably efficacious. Substantial variability in effectiveness of different programs within the same treatment family has been previously documented; thus, a particular level of evidence might not hold true for every individual program in a treatment family. Systematic investigations of implementation, dissemination, and uptake are needed to ensure that children and families have access to effective treatments. Investigations into how to blend the strengths of the effective approaches into even more effective treatment might also lead to greater impact.

Alcohol use, depression, and life satisfaction among older persons in Jamaica

BACKGROUND

We aimed to determine the prevalence of alcohol use among older Jamaicans as well as to explore among this population the relationships between alcohol use and: age, sex, depressive symptoms, and life satisfaction. Although the nature of these relationships among the proposed study population were uncertain, in other settings alcohol use has tended to decline with increasing age, occur more commonly among men than women, and show non-linear relationships with depressive symptoms and life satisfaction.

METHODS

Data gathered by two-stage cluster sampling for a nationally representative health and lifestyle survey of 2,943 community-dwelling older Jamaicans, aged 60 to 103 years, were subjected to secondary analysis using the Student's t-test and χ 2 test as appropriate.

RESULTS

Current alcohol use was reported by 21.4% of the participants. It steadily declined with age and was six times more prevalent among men (37.6%) than women (6.2%). These findings were statistically significant as were associations of current alcohol use with comparatively lower levels of depressive symptoms. Current alcohol use was also more prevalent among persons who were either highly satisfied or highly dissatisfied with their lives, compared to others who had levels of life satisfaction between these two extremes.

CONCLUSIONS

Current alcohol use among older Jamaicans occurs primarily among men, declines with increasing age, and is associated with a relatively low likelihood of depression. It is also associated with very high and very low levels of life satisfaction.

Early childhood development coming of age: science through the life course

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

Converging on child mental health - toward shared global action for child development

We are a group of researchers and clinicians with collective experience in child survival, nutrition, cognitive and social development, and treatment of common mental conditions. We join together to welcome an expanded definition of child development to guide global approaches to child health and overall social development. We call for resolve to integrate maternal and child mental health with child health, nutrition, and development services and policies, and see this as fundamental to the health and sustainable development of societies. We suggest specific steps toward achieving this objective, with associated global organizational and resource commitments. In particular, we call for a Global Planning Summit to establish a much needed Global Alliance for Child Development and Mental Health in all Policies.

The Incredible Years Parents and Babies Program: A Pilot Randomized Controlled Trial

INTRODUCTION

Infancy is an important period of life; adverse experiences during this stage can have both immediate and lifelong impacts on the child's mental health and well-being. This study evaluates the effects of offering the Incredible Years Parents and Babies (IYPB) program as a universal intervention.

METHOD

We conducted a pragmatic, two-arm, parallel pilot randomized controlled trial; 112 families with newborns were randomized to the IYPB program (76) or usual care (36) with a 2:1 allocation ratio. The primary outcome was parenting confidence at 20 weeks(Karitane Parenting Confidence Scale and Parental Stress Scale). Secondary outcomes include measures of parent health, parent-child relationship, infant development, parent-child activities, and network. Interviewers and data analysts were blind to allocation status. Multiple linear-regression analyses were used for evaluating the effects of the intervention.

RESULTS

There were no intervention effects on the primary outcomes. Only one effect was detected for secondary outcomes, intervention mothers reported a significantly smaller network than control mothers (β = -0.15 [-1.85,-0.28]). When examining the lowest-functioning mothers in moderator analyses, we found that intervention mothers reported significantly higher parent stress (β = 5.33 [0.27,10.38]), lower parenting confidence (β = -2.37 [-4.45,-0.29]), and worse mental health than control mothers (β = -18.62 [-32.40,-4.84]). In contrast, the highest functioning intervention mothers reported significantly lower parent stress post-intervention (β = -6.11 [-11.07,-1.14]).

CONCLUSION

Overall, we found no effects of the IYPB as a universal intervention for parents with infants. The intervention was developed to be used with groups of low functioning families and may need to be adapted to be effective with universal parent groups. The differential outcomes for the lowest and highest functioning families suggest that future research should evaluate the effects of delivering the IYPB intervention to groups of parents who have similar experiences with parenting and mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01931917.

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.

What is known about school-based interventions for health promotion and their impact in developing countries? A scoping review of the literature

Schools can play an important role in health promotion mainly by improving students' health literacy, behaviors and academic achievements. School-based health promotion can be particularly valuable in developing countries facing the challenges of low health literacy and high burden of disease. We conducted a scoping review of the published literature focusing on school-based interventions for health promotion and their impact in developing countries. We included 30 studies meeting specific criteria: (i) studies mainly targeted school going children or adolescents; (ii) admissible designs were randomized controlled trials, controlled before-after studies or interrupted time series; (iii) studies included at least one measure of impact and (iv) were primary studies or systematic reviews. We found that school-based interventions can be classified in two main categories: those targeting individual determinants of health such as knowledge, skills and health behaviors and those targeting environmental determinants such as the social and physical environment at the school, family and community level. Findings suggest that a comprehensive approach addressing both individual and environmental determinants can induce long-term behavior change and significantly improve health and educational outcomes. We highlight the need for further study of the long-term impact of school-based interventions on health outcomes in developing countries.

Short-term effects of the "Together at School" intervention program on children's socio-emotional skills: a cluster randomized controlled trial

BACKGROUND

Together at School is a universal intervention program designed to promote socio-emotional skills among primary-school children. It is based on a whole school approach, and implemented in school classes by teachers. The aim of the present study is to examine the short-term effects of the intervention program in improving socio-emotional skills and reducing psychological problems among boys and girls. We also examine whether these effects depend on grade level (Grades 1 to 3) and intervention dosage.

METHODS

This cluster randomized controlled trial design included 79 Finnish primary schools (40 intervention and 39 control) with 3 704 children. The outcome measures were the Strengths and Difficulties Questionnaire (SDQ) and the Multisource Assessment of Social Competence Scale (MASCS) with teachers as raters. The intervention dosage was indicated by the frequencies six central tools were used by the teachers. The data was collected at baseline and 6 months later. Intervention effects were analyzed using multilevel modeling.

RESULTS

When analyzed across all grades no intervention effect was observed in improving children's socio-emotional skills or in reducing their psychological problems at 6-month follow-up. Among third (compared to first) graders the intervention decreased psychological problems. Stratified analyses by gender showed that this effect was significant only among boys and that among them the intervention also improved third graders' cooperation skills. Among girls the intervention effects were not moderated by grade. Implementing the intervention with intended intensity (i.e. a high enough dosage) had a significant positive effect on cooperation skills. When analyzed separately among genders, this effect was significant only in girls.

CONCLUSIONS

These first, short-term results of the Together at School intervention program did not show any main effects on children's socio-emotional skills or psychological problems. This lack of effects may be due to the relatively short follow-up period given the universal, whole school-based approach of the program. The results suggest that the grade level where the intervention is started might be a factor in the program's effectiveness. Moreover, the results also suggest that for this type of intervention program to be effective, it needs to be delivered with a high enough dosage.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02178332 ; Date of registration: 03-April-2014.

Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschools

INTRODUCTION

We aim to determine the effectiveness of a school-based violence prevention programme implemented in Jamaican preschools, on reducing the levels of aggression among children at school, and violence against children by teachers.

METHODS AND ANALYSIS

This is a 2-arm, single-blind, cluster-randomised controlled trial with parallel assignment. Clusters are 76 preschools in Kingston, and all teachers and classrooms in the selected schools are included in the study. In addition, a random sample of up to 12 children in the 4-year-old classes have been selected for evaluation of child-level outcomes. The intervention involves training teachers in classroom behaviour management and in strategies to promote children's social-emotional competence. Training is delivered through five full-day workshops, monthly in-class coaching over 2 school terms, and weekly text messages. The primary outcome measures are: (1) observed levels of child aggression and (2) observed violence against children by teachers. Secondary outcomes include observations of the levels of children's prosocial behaviour and the quality of the classroom environment, teachers' reports of their mental health, teacher-reported child mental health, direct tests of children's self-regulation and child attendance.

ETHICS AND DISSEMINATION

If this intervention were effective at improving the caregiving environment of young children in school, this would have significant implications for the prevention of child mental health problems, and prevention of violence against children in low and middle-income countries where services are often limited. The intervention is integrated into the school system and involves training existing staff, and thus, represents an appropriate strategy for large-scale implementation and benefits at the population level. Ethical consent for the study was given by the School of Psychology Ethics and Research Committee, Bangor University (ref: 2014-14167), and by the University of the West Indies Ethics Committee (ref: ECP 50,14/15).

TRIAL REGISTRATION NUMBER

ISRCTN11968472; Pre-results.

The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in Uganda

Background

Violence against children from school staff is widespread in various settings, but few interventions address this. We tested whether the Good School Toolkit—a complex behavioural intervention designed by Ugandan not-for-profit organisation Raising Voices—could reduce physical violence from school staff to Ugandan primary school children.

Methods

We randomly selected 42 primary schools (clusters) from 151 schools in Luwero District, Uganda, with more than 40 primary 5 students and no existing governance interventions. All schools agreed to be enrolled. All students in primary 5, 6, and 7 (approximate ages 11–14 years) and all staff members who spoke either English or Luganda and could provide informed consent were eligible for participation in cross-sectional baseline and endline surveys in June–July 2012 and 2014, respectively. We randomly assigned 21 schools to receive the Good School Toolkit and 21 to a waitlisted control group in September, 2012. The intervention was implemented from September, 2012, to April, 2014. Owing to the nature of the intervention, it was not possible to mask assignment. The primary outcome, assessed in 2014, was past week physical violence from school staff, measured by students' self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool—Child Institutional. Analyses were by intention to treat, and are adjusted for clustering within schools and for baseline school-level means of continuous outcomes. The trial is registered at clinicaltrials.gov, NCT01678846.

Findings

No schools left the study. At 18-month follow-up, 3820 (92·4%) of 4138 randomly sampled students participated in a cross-sectional survey. Prevalence of past week physical violence was lower in the intervention schools (595/1921, 31·0%) than in the control schools (924/1899, 48·7%; odds ratio 0·40, 95% CI 0·26–0·64, p<0·0001). No adverse events related to the intervention were detected, but 434 children were referred to child protective services because of what they disclosed in the follow-up survey.

Interpretation

The Good School Toolkit is an effective intervention to reduce violence against children from school staff in Ugandan primary schools.

Funding

MRC, DfID, Wellcome Trust, Hewlett Foundation.

Prevalence of Children's Mental Health Problems and the Effectiveness of Population-Level Family Interventions

The prevalence of mental health problems among children and adolescents is of growing importance. Intervening in children’s mental health early in life has been shown to be more effective than trying to resolve these problems when children are older. With respect to prevention activities in community settings, the prevalence of problems should be estimated, and the required level of services should be delivered. The prevalence of children’s mental health disorders has been reported for many countries. Preventive intervention has emphasized optimizing the environment. Because parents are the primary influence on their children’s development, considerable attention has been placed on the development of parent training to strengthen parenting skills. However, a public-health approach is necessary to confirm that the benefits of parent-training interventions lead to an impact at the societal level. This literature review clarifies that the prevalence of mental health problems is measured at the national level in many countries and that population-level parenting interventions can lower the prevalence of mental health problems among children in the community.

Challenges in Providing Child and Adolescent Psychiatric Services in Low Resource Countries

Ninety percent of the world's children and adolescents live in low resource countries; and nearly one-half of all mental disorders begin before age 14. The prevalence of child and adolescent mental disorders in low resource countries is around 20%. Fewer than 25% of children and adolescents with psychiatric disorders receive treatment. Resources are insufficient, inequitably distributed, and inefficiently utilized; treatment and care are often neither evidence based nor of comprehensive or of high quality. Nationally, child and adolescent mental health policies and standardized training are virtually nonexistent. This article highlights the challenges faced and discusses measures to overcome them.

The effectiveness of the Incredible Years™ Parents and Babies Program as a universal prevention intervention for parents of infants in Denmark: study protocol for a pilot randomized controlled trial

BACKGROUND

Infancy is an important period in a child's life, with rapid growth and development. Early experiences shape the developing brain, and adverse experiences can have both an immediate and lifelong impact on health and wellbeing. Parenting interventions offered to parents of newborns can support parents in providing sensitive and responsive care, and reinforce healthy development for their infants. This study aims to evaluate the impact of the Incredible Years™ Parents and Babies Program in a universal setting for parents with infants.

METHODS/DESIGN

This is a pragmatic, two-arm, parallel, pilot, randomized controlled trial (RCT) where 128 families with newborn infants up to four-months-old are recruited in two municipalities in Denmark. Families are randomized to the Incredible Years Parents and Babies Program or usual care with a 2:1 allocation ratio. The primary outcome is parenting confidence measured after 20 weeks by the Karitane Parenting Confidence Scale and Parental Stress Scale. Secondary outcomes include measures of parent health, reflective functioning, relationship with the infant, and infant development. Interviewers and data analysts are blind to allocation status.

DISCUSSION

This is the first RCT of the Incredible Years Parents and Babies Program, and one of the first rigorous evaluations of a universally offered preventive intervention for parents with infants. The trial will provide important information on the effectiveness of a relatively brief, universally offered parenting intervention for parents of infants, and will also provide information on infant measures, parent recruitment and participation, and implementation of the program, which could inform future trials.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (identifier: NCT01931917) on 27 August 2013.

Understanding influences on teachers' uptake and use of behaviour management strategies within the STARS trial: process evaluation protocol for a randomised controlled trial

Background

The ‘Supporting Teachers And childRen in Schools’ (STARS) study is a cluster randomised controlled trial evaluating the Incredible Years Teacher Classroom Management (TCM) programme as a public health intervention. TCM is a 6 day training course delivered to groups of 8–12 teachers. The STARS trial will investigate whether TCM can improve children’s behaviour, attainment and wellbeing, reduce teachers’ stress and improve their self-efficacy. This protocol describes the methodology of the process evaluation embedded within the main trial, which aims to examine the uptake and implementation of TCM strategies within the classroom plus the wider school environment and improve the understanding of outcomes.

Methods/design

The STARS trial will work with eighty teachers of children aged 4–9 years from eighty schools. Teachers will be randomised to attend the TCM course (intervention arm) or to “teach as normal” (control arm) and attend the course a year later. The process evaluation will use quantitative and qualitative approaches to assess fidelity to model, as well as explore headteachers’ and teachers’ experiences of TCM and investigate school factors that influence the translation of skills learnt to practice. Four of the eight groups of teachers (n = 40) will be invited to participate in focus groups within one month of completing the TCM course, and again a year later, while 45 of the 80 headteachers will be invited to take part in telephone interviews. Standardised checklists will be completed by group leaders and each training session will be videotaped to assess fidelity to model. Teachers will also complete standardised session evaluations.

Discussion

This study will provide important information about whether the Teacher Classroom Management course influences child and teacher mental health and well-being in both the short and long term. The process evaluation will provide valuable insights into factors that may facilitate or impede any impact.

Trial registration

The trial has been registered with ISCTRN (Controlled Trials Ltd) and assigned an ISRCTN number ISRCTN84130388. Date assigned: 15 May 2012.

Global development and diffusion of outcome evaluation research for interpersonal and self-directed violence prevention from 2007 to 2013: A systematic review

Through a global review, we identified gaps in the geographical distribution of violence prevention evidence outcome evaluation studies and the types of violence addressed. Systematic literature searches identified 355 articles published between 2007 and 2013 that evaluated programs to prevent interpersonal or self-directed violence; focused on universal or selected populations; and reported outcomes measuring violence or closely related risk factors. The number of studies identified increased annually from 2008 (n = 37), reaching 64 in 2013. Over half (n = 203) of all studies focused on youth violence yet only one on elder maltreatment. Study characteristics varied by year and violence type. Only 9.3% of all studies had been conducted in LMICs. These studies were less likely than those in high income countries (HICs) to have tested established interventions yet more likely to involve international collaboration. Evaluation studies successfully established in LMIC had often capitalized on other major regional priorities (e.g. HIV). Relationships between violence and social determinants, communicable and non-communicable diseases, and even economic prosperity should be explored as mechanisms to increase the global reach of violence prevention research. Results should inform future research strategies and provide a baseline for measuring progress in developing the violence prevention evidence-base, especially in LMICs.

A randomized controlled trial of the impact of a teacher classroom management program on the classroom behavior of children with and without behavior problems

This randomized controlled trial (RCT) evaluated the efficacy of the Incredible Years (IY) Teacher Classroom Management (TCM; Webster-Stratton & Reid, 2002) program to assess whether training teachers in IY-TCM principles improve teacher behavior, whether any observed improvements impact pupil behavior classroom-wide, and whether these effects can be demonstrated with children at risk of developing conduct problems. Six intervention and six control classrooms comprising 12 teachers and 107 children (aged 3 to 7years) were recruited. Children were screened for high or low behavior problems using the cut-off points of the teacher-rated Strengths and Difficulties Questionnaire (Goodman, 1997). The primary outcome measure was independent classroom observations using the Teacher-Pupil Observation Tool (Martin et al., 2010). Multilevel modeling analyses were conducted to examine the effect of the intervention on teacher, classroom, and child behavior. Results showed a significant reduction in classroom off-task behavior (d=0.53), teacher negatives to target children (d=0.36), target child negatives towards the teacher (d=0.42), and target child off-task behavior (d=0.48). These preliminary results demonstrate the potential impact of IY-TCM on both teacher and child behavior.