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

How do schools influence the emotional and behavioural health of their pupils? A multi-level analysis of 135 schools in the Born in Bradford inner city multi-ethnic birth cohort

PURPOSE

To estimate variation in emotional and behavioural problems between primary schools in Bradford, an ethnically diverse and relatively deprived city in the UK.

METHODS

We did a cross-sectional analysis of data collected from 2017 to 2021 as part of the 'Born In Bradford' birth cohort study. We used multilevel linear regression in which the dependent variable was the Strengths and Difficulties Questionnaire (SDQ) total score, with a random intercept for schools. We adjusted for pupil-level characteristics including age, ethnicity, socioeconomic status, and parental mental health.

RESULTS

The study included 5,036 participants from 135 schools. Participants were aged 7-11 years and 56% were of Pakistani heritage. The mean SDQ score was 8.84 out of a maximum 40. We estimated that the standard deviation in school-level scores was 1.41 (95% CI 1.11-1.74) and 5.49% (95% CI 3.19-9.37%) of variation was explained at school level. After adjusting for pupil characteristics, the standard deviation of school-level scores was 1.04 (95% CI 0.76-1.32) and 3.51% (95% CI 1.75-6.18%) of variation was explained at school level. Simulation suggested that a primary school with 396 pupils at the middle of the distribution has 63 pupils (95% CI 49-78) with a 'raised' SDQ score of 15 + /40; and shifting a school from the lower to the upper quartile would prevent 26 cases (95% CI 5-46).

CONCLUSION

The prevalence of emotional and behavioural problems varies between schools. This is partially explained by pupil characteristics; though residual variation in adjusted scores may suggest that schools have a differential impact on mental wellbeing.

Cultural adaptation, content, and protocol of a feasibility study of school-based "Let's learn about emotions" intervention for Finnish primary school children

Introduction

Emotional awareness and emotion regulation are crucial for cognitive and socio-emotional development in children. School-based interventions on socio-emotional skills have the potential to prevent these problems and promote well-being of children. The Japanese school-based program, Universal Unified Prevention Program for Diverse Disorders (Up2-D2), has shown preventive effects on mental health of children in Japan. The aims of this protocol paper are to describe the unique process of adapting the Up2-D2 from Eastern to Western context, and to present a feasibility study of the intervention, conducted in Finland.

Methods

The cultural adaptation process started with the linguistic translation of materials, followed by the modification of language to fit the Finnish context. While the Japanese ideology was saved, some content was adapted to fit Finnish school children. Further modifications were made based on feedback from pupils and teachers. The Finnish version of the program was named "Let's learn about emotions" and consisted of 12 sessions and targeted 8- to 12-year-old pupils. A teacher education plan was established to assist Finnish teachers with the intervention, including a workshop, teachers' manual, brief introductory videos, and online support sessions. A feasibility study involving 512 4th graders in the City of Hyvinkää, South of Finland, was conducted. It assessed emotional and behavioral problems, classroom climate, bullying, loneliness, perception of school environment, knowledge of emotional awareness, and program acceptability.

Discussion

The originality of this study underlies in the East-West adaptation of a cognitive behavioral therapy-based program. If promising feasibility findings are replicated in Finland, it could pave the way for further research on implementing such programs in diverse contexts and cultures, promoting coping skills, awareness, social skills and early prevention of child mental health problems.

Ethics

The ethical board of the University of Turku gave ethics approval for this research. The educational board of the City of Hyvinkää accepted this study.

Systematic review and meta-analysis of the prevention of internalizing disorders in early childhood

Introduction

Internalizing problems comprise a significant amount of the mental health difficulties experienced during childhood. Implementing prevention programs during early childhood may prevent internalizing problems. The present systematic review and meta-analysis aimed to evaluate the effect of both targeted and universal prevention programs in preventing internalizing problems for children aged 3- to 5-years and their parents.

Methods

PsycINFO, Embase, and MEDLINE were systematically searched, and 17 randomized control trials, consisting of 3,381 children, met eligibility criteria. There were seven universal prevention programs, and 10 targeted prevention programs. Four prevention programs were delivered to children, 10 prevention programs were delivered to parents/caregivers, and three prevention programs were delivered to both parents and children.

Results

Prevention programs led to significantly fewer internalizing problems at 6- and 7-month post-intervention (n = 7, p = 0.02, CI -0.69, 0.06) with a small-to-moderate effect size (g = -0.38), however, not at post-intervention or at 12-month follow up.

Discussion

Overall, findings suggest that there may be value in ongoing development and evaluation of prevention programs for internalizing problems, as they improve social and emotional wellbeing in students and reduce internalizing difficulties within the 6- to 7-month timeframe following prevention programs.

Systematic review registration

PROSPERO: CRD42021261323.

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.

Excess healthcare costs of mental disorders in children, adolescents and young adults in the Basque population registry adjusted for socioeconomic status and sex

BACKGROUND

Mental illnesses account for a considerable proportion of the global burden of disease. Economic evaluation of public policies and interventions aimed at mental health is crucial to inform decisions and improve the provision of healthcare services, but experts highlight that nowadays the cost implications of mental illness are not properly quantified. The objective was to measure the costs of excess use of all healthcare services by 1- to 30-year-olds in the Basque population as a function of whether or not they had a mental disorder diagnosis.

METHODS

A real-world data study was used to identify diagnoses of mental disorders and to measure resource use in the Basque Health Service Registry in 2018. Diagnoses were aggregated into eight diagnostic clusters: anxiety, attention deficit hyperactivity disorder, conduct disorders, mood disorders, substance use, psychosis and personality disorders, eating disorders, and self-harm. We calculated the costs incurred by each individual by multiplying the resource use by the unit costs. Annual costs for each cluster were compared with those for individuals with no diagnosed mental disorders through entropy balancing and two-part models which adjusted for socioeconomic status (SES).

RESULTS

Of the 609,381 individuals included, 96,671 (15.9%) had ≥ 1 mental disorder diagnosis. The annual cost per person was two-fold higher in the group diagnosed with mental disorders (€699.7) than that with no diagnoses (€274.6). For all clusters, annual excess costs associated with mental disorders were significant. The adjustment also evidenced a social gradient in healthcare costs, individuals with lower SES consuming more resources than those with medium and higher SES across all clusters. Nonetheless, the effect of being diagnosed with a mental disorder had a greater impact on the mean and excess costs than SES.

CONCLUSIONS

Results were consistent in showing that young people with mental disorders place a greater burden on healthcare services. Excess costs were higher for severe mental disorders like self-harm and psychoses, and lower SES individuals incurred, overall, more than twice the costs per person with no diagnoses. A socioeconomic gradient was notable, excess costs being higher in low SES individuals than those with a high-to-medium SES. Differences by sex were also statistically significant but their sizes were smaller than those related to SES.

Accessible mental well-being intervention for adolescents in school settings: a single-group intervention study using a pretest-post-test design

BACKGROUND

A growing number of adolescents seek treatment for mental health problems, a circumstance that stresses the importance of implementing accessible treatment options. This study evaluates the impacts of brief, mental well-being intervention for adolescents in a school environment. As mental health interventions are often targeted at specific disorders, we sought a comprehensive approach to reach adolescents with a range of mental health symptoms.

METHODS

Single-group intervention study with a pretest-posttest design was utilized and conducted in lower, upper secondary, and vocational schools on adolescents ages 12-18 who sought medical attention for mental health symptoms. The cut-off point for inclusion was ≥ 14, for the Young Persons Clinical Outcomes for routine Evaluation (YP-CORE) measurement. The intervention included six face-to-face visits implemented by psychiatric nurses who received a 3-day training course. The impacts were evaluated after 6 weeks (n = 87) and again at 6 months (n = 68) and assessed using the YP-CORE, Beck Depression Inventory (BDI-II) and Overall Anxiety Severity and Impairment Scale (OASIS).

RESULTS

The participants reported significant levels of mental distress at baseline with a YP-CORE mean score = 21.48, a BDI-II mean score = 23.60, OASIS mean score = 10.98. Post-intervention results at 6 weeks for the primary outcome YP-CORE showed a significant (p < .001) mean score decrease of - 3.82, a medium effect size d = .627. For participants attending upper secondary and vocational schools the YP-CORE scores changed significantly from baseline to 6-weeks (p = .005) and from baseline to 6-months (p < .001). Long-term outcomes at 6-months showed a - 1.14 decrease (p = non-significant), effect size d = .175. After the 6-week intervention, 12% of the participants were assessed as not requiring additional visits.

CONCLUSIONS

This easily accessible intervention in a school setting indicated improvement for those participants with mild to moderate mental disorder symptoms and attending upper secondary and vocational schools. After the 6-week intervention, significant positive effects were observed. Participants reported substantial levels of mental distress at the baseline, which could contribute to the decline of symptoms and need for extended care during the 6 months follow-up. Trial registration Retrospectively registered with Clinicaltrials.gov identifier NCT05356949.

Efficacy of school-based interventions for mental health problems in children and adolescents in low and middle-income countries: A systematic review and meta-analysis

Background

Implementation of interventions to treat child and adolescent mental health problems in schools could help fill the mental health care gap in low- and middle-income countries (LMICs). Most of the evidence available come from systematic reviews on mental health prevention and promotion, and there is less evidence on treatment strategies that can be effectively delivered in schools. The aim of this review was to identify what school-based interventions have been tested to treat children and adolescents in LMICs, and how effective they are.

Methods

We conducted a systematic review including seven electronic databases. The search was carried out in October 2022. We included randomised or non-randomised studies that evaluated school-based interventions for children or adolescents aged 6-18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems.

Results

We found 39 studies with 43 different pairwise comparisons, treatment for attention-deficit and hyperactivity (ADHD), anxiety, depression, and posttraumatic stress disorder (PTSD), Conduct disorder (CD). Pooled SMD were statistically significant and showed that, overall, interventions were superior to comparators for PTSD (SMD = 0.61; 95% CI = 0.37-0.86), not statistically significant for anxiety (SMD = 0.11; 95% CI = -0.13 to 0.36), ADHD (SMD = 0.36; 95% CI = -0.15 to 0.87), and for depression (SMD = 0.80; 95% CI = -0.47 to 2.07). For CD the sample size was very small, so the results are imprecise.

Conclusion

A significant effect was found if we add up all interventions compared to control, suggesting that, overall, interventions delivered in the school environment are effective in reducing mental health problems among children and adolescents.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=129376], identifier [CRD42019129376].

Commentary/Response: Economic evidence should be routinely collected and reported for studies of intervention effectiveness in mental health. A commentary on Vartiainen et al. (2022)

Anxiety and related disorders are increasingly widespread amongst children and adolescents. Preventing mental health disorders from developing has the potential to realise long-term benefits for children and adolescents. In their paper, 'Economic evidence of preventive interventions for anxiety disorders in children and adolescents-a systematic review', Vartiainen et al. conducted a systematic review to examine economic evidence of interventions for the primary prevention of anxiety disorders in children and adolescents, under 18 years of age. Five articles were eligible for inclusion in the review, of which two were model-based economic evaluations and three conducted alongside randomised controlled trials (RCTs). All five papers used either a cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) as their main analysis. Vartiainen et al. concluded that, due to the small number of studies and relatively small sample sizes, the evidence for the cost-effectiveness of anxiety prevention interventions is weak. In this commentary, the challenges of conducting economic evaluations for prevention interventions are briefly outlined and Vartiainen et al.'s findings are discussed in the context of two further reviews of economic studies, published in 2021. The first focuses on the prevention of anxiety and depression in children and young people and the second takes a broader perspective and also includes interventions for mental health promotion. Both additional reviews note the small number of published economic evaluations, and all three reviews are united in their call for economic evaluations to be conducted alongside all future mental health prevention intervention trials.