Training teachers in classroom management to improve mental health in primary school children: the STARS cluster RCT

The cost-effectiveness of school-based interventions for chronic diseases: a systematic review

BACKGROUND

Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

METHODS

We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

RESULTS

Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

CONCLUSION

Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Reporting involvement activities with children and young people in paediatric research: a framework analysis

BACKGROUND

The active involvement of patients and the public in the design and delivery of health research has been increasingly encouraged, if not enforced. Knowledge of how this is realised in practice, especially where children and young people (CYP) are concerned, is limited, partly due to the low level of reporting of patient and public involvement (PPI) in general. The aim of this work was to assess how researchers funded by the National Institute for Health and Care Research (NIHR) report the involvement of CYP in the design and conduct of child health research to better understand the opportunities offered to CYP, and the realities of involvement in practice.

METHODS

A participation matrix, analysis framework and accompanying tools were adapted from existing frameworks, including a child-rights informed framework, the Guidance for Reporting Involvement of Patients and the Public Checklist Short Form (GRIPP2SF), and NIHR reporting expectations. Child-focused research reports were identified from the NIHR Journals Library, including any interventional or observational study involving CYP aged 0-< 24 years. In two co-design workshops with healthcare professionals and CYP, we tested and refined the participation matrix, analysis framework and accompanying tools.

RESULTS

Only thirty-two NIHR reports out of 169 (19%) were identified as relevant and included reporting of PPI with CYP. We identified significant variability in the way PPI with CYP was reported. Only 4/32 (12%) reports fully met NIHR (and GRIPP2SF) reporting criteria. Only 3/32 (9%) reports formally evaluated or self-reflected on PPI activities with CYP, whilst 15/32 (47%) provided minimal information about CYP involvement. The most common approach to involving CYP (23/32, 72%) was through the medium of existing groups or networks.

CONCLUSION

Despite the NIHR's commitment to increase the quality, transparency, and consistency of reporting PPI, the reporting of involvement with CYP remains sub-optimal. Neglecting to report key details of involvement methods and impacts deprives the research community of knowledge to advance the field of delivering 'meaningful' PPI with CYP. Practical guidance on how researchers can report the processes and outputs of CYP involvement more rigorously may help child health researchers to involve them more meaningfully. This research offers practical tools informed by CYP to aid the reporting process.

Schulprogramme zur Förderung der psychischen Gesundheit. Die psychische Gesundheitskompetenz von Lehrpersonen als wichtiger Umsetzungsfaktor

Hintergrund

Weltweit sind bis zu einem Fünftel der Kinder und Jugendlichen von psychischen Störungen betroffen. Auffälligkeiten, die bereits im Schulalter auftreten, sind insbesondere für die Betroffenen, aber auch die Lehrpersonen belastend. Schulische Präventionsprogramme zur psychischen Gesundheit haben das Potenzial, die Belastungen beidseitig zu reduzieren. Die psychische Gesundheitskompetenz von Lehrpersonen, die nicht nur das Wissen und das Verständnis, sondern auch die Handlungen untersucht, gilt dabei als wichtiger Umsetzungsfaktor. Die Studienlage ist mager.

Ziele

Die Studie untersucht die psychische Gesundheitskompetenz von Lehrpersonen im Kontext von Belastungssituation der Schülerinnen und Schüler sowie das Vorhandensein entsprechender Schulprogramme.

Methoden

Im Schuljahr 2019/2020 wurden alle Lehrpersonen in einer Deutschschweizer Stadt zu einem Online-Survey eingeladen (n = 1514; Rücklauf: 38 %). Die Daten wurden quantitativ mittels bivariater und multivariater Methoden ausgewertet. Eine offene Frage zum Verständnis psychischer Störungen wurde qualitativ mittels einer Inhaltsanalyse ausgewertet.

Resultate und Diskussion

Die Befragten betreuten oder unterrichteten im letzten Jahr durchschnittlich 4,7 psychisch belastete Schülerinnen und Schülern. Die Anzahl Betroffener unterschied sich nach Schulstufe und Schulfunktion. Die Lehrpersonen schätzten ihre Fähigkeit, Informationen zum Thema zu finden und zu verstehen als (sehr) gut ein, es fiel ihnen jedoch schwerer, zu beurteilen, ob die gefundenen Informationen korrekt sind. Die Handlungskompetenz der Lehrkräfte war partiell gering, beispielsweise beim Wissen über Störungsbilder und stellt ein Hindernis in der Umsetzung von Schulprogrammen dar. Lehrkräfte relativierten auffälliges Verhalten, was die Triage für weitere Abklärungen erschwert. Den Schulen wird zum einen empfohlen in die Eigeninitiative der Lehrpersonen zu investieren, zum anderen sollte die Steigerung der psychischen Gesundheitskompetenz nicht nur Aufgabe der Lehrpersonen sein, sondern durch eine entsprechende Schulkultur und gesellschaftlich gefördert werden.

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

Background

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

Aims

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

Sample

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

Methods

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

Results

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

Conclusion

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

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.

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

BACKGROUND

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

AIMS

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

SAMPLE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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