The mental health of children and young people is an area of growing concern. Recent estimates suggest one in six young people aged 5 to 16 years are currently experiencing mental health difficulties (Vizard et al, 2020), and only a quarter of those with a mental health condition are in contact with child and adolescent mental health services (Sadler et al, 2018).
Given the majority of students will not have direct access to mental health services, schools have become a place of great interest in prevention (Patel et al, 2018).
As set-out in the government’s green paper Transforming Children and Young People’s Mental Health (Department of Health, 2017), the school setting provides an opportunity to reach large numbers of young people simultaneously. Educators spend significant time with young people, which provides them with an opportunity to develop a trusting and supportive relationship (Fazel et al, 2014). School staff are also commonly consulted by parents and students on what to do in relation to mental health or behavioural concerns. It is essential that we use reliable evidence to inform decisions made by policymakers and professionals about what should be delivered in schools.
In the current study (Clarke et al, 2021), the authors aimed to identify the latest evidence on the effectiveness of school-based interventions designed to address the emotional and behavioural needs of young people aged 12-18 years.
One in six young people aged 5 to 16 years has experienced mental health difficulties. Schools can provide an accessible way to deliver mental health prevention programs.
Methods
The authors searched three databases (PsycINFO, SCOPUS, Web of Science) with clearly described search terms to identify school-based mental health interventions. Authors searched for meta-analyses published between January 2010 and August 2020, and primary studies published between January 2017 and August 2020.
To be included, the interventions needed to be delivered in secondary schools to young people aged 12-18 years. Only empirical studies that used quantitative methods were included. Interventions delivered to people working with adolescents in secondary schools were included if the study reported students’ outcomes, rather than staff training or competency outcomes.
Experts in the fields were consulted and manual searches were conducted on Google Scholar. Authors also searched the references contained in the identified review papers.
A narrative synthesis of the findings was presented for the systematic reviews and primary studies.
Results
The authors included a total of 34 review papers published since 2010, and 97 primary studies published over the past three years.
Key findings showed:
- The majority of prevention interventions were based on Cognitive Behavioural Therapy (CBT). Interventions delivered by external professionals showed good evidence in reducing symptoms of depression in young people with subclinical symptoms, both in short and medium term.
- Social and emotional learning interventions (SEL) are curriculum-based and whole-school programmes focused on developing students’ emotional and social skills. SEL interventions were shown to have a small to moderate impact on young people’s social and emotional skills and symptoms of depression and anxiety in the short term.
- Mindfulness, positive psychology, and positive youth development interventions showed limited evidence of effectiveness.
- Mental health literacy interventions were shown to have a positive impact on young people’s knowledge on mental health. However, the evidence is limited on whether these interventions impact attitudes towards mental health, stigma, and help-seeking behaviour.
- Interventions on preventing suicide and self-harm were limited and studies on gatekeeper training were of weak quality.
- Whole-school interventions are particularly effective in reducing bullying behaviour. However, none of the primary studies examined the impact of interventions to prevent cyberbullying.
- Universal sexual violence prevention interventions showed a small positive impact on improving knowledge and attitudes, but minimal impact on perpetration and victimisation. These interventions had a greater positive impact when embedded within a wider whole-school approach.
- Teachers were shown to be effective programme facilitators when delivering universal interventions. However, there is no evidence that teacher-delivered interventions are effective in addressing the needs of students with symptoms of depression or anxiety.
This review provides a top-level summary about the best school-based interventions to support the mental health of 12-18 year olds.
Conclusions
This review highlights that school-based mental health and behavioural interventions have the potential to address some of the biggest challenges that children and young people are currently facing. Specifically, it highlights that interventions using CBT and targeting symptoms of depression and anxiety, or reducing aggressive behaviour, bullying perpetration and victimisation were most effective; with effects more pronounced in subclinical populations. However, it also highlights that interventions are not universally effective, require careful implementation, and in many cases further research is desperately needed – meaning when it comes to school-based mental health interventions, some caution is still required.
School-based interventions using a CBT approach to target symptoms of depression and anxiety have a strong evidence-base.
Strengths and limitations
The current review paper provides a thorough synthesis of school-based mental health interventions. Numerous mental health interventions are available for schools to use, however due to limited resources it can be a challenge to decide which interventions to implement. This review bridges the gap and provides a comprehensive list of existing effective interventions.
However, by the authors’ own acknowledgement, there are a number of limitations to this review.
Firstly, a meta-analysis of the primary studies was not conducted making it difficult to fully synthesise and assess the strength of the evidence. However, as the authors note, it is likely that the majority of relevant studies would have been included within the systematic reviews. Therefore this decision may have limited effect on conclusions.
The possibility of publication bias should be carefully considered, as studies with more positive results are more likely to be published. There may be additional evidence highlighting the ineffectiveness of interventions which this review may not have captured – leading to biased results.
A final limitation: the current review did not extract intervention-specific data from the systematic review studies, instead reporting the overarching results from these reviews. Comparing the components within and across interventions can further explain why an intervention was effective or not.
Numerous mental health interventions are available for schools to use, however due to limited resources it can be a challenge to decide which interventions to implement.
Implications for practice
The current review presents key findings that have important implications for practice, policy, and research. Schools should be supported, and provided the tools, to successfully implement evidence-based interventions. This will likely require additional, targeted investment in resources and training, including up-skilling school staff in the early identification of vulnerable learners.
This review reveals significant gaps within the existing evidence leading the authors to identify key priority areas for future research. For example, limited interventions addressing cyberbullying, conduct problems and self-harm were identified. Evidence exploring the development and evaluation of targeted interventions for ‘at risk groups’ including those from ethnic minorities, lower socioeconomic status, and with Special Educational Needs were among those established as requiring further investigation. We further recommend that interventions for those at risk of school exclusion should also be considered a research priority.
In addition, the authors identify more longitudinal research is needed with careful description of intervention dosage and adherence. At present it is difficult to understand if the success or failure of a programme is due to the intervention itself, or the way it was implemented.
How an intervention is implemented can be important. It is essential that school and mental health communities continue to collaborate in the generation of further high quality evidence.
Statement of interests
No conflicts of interest.
Links
Primary paper
Clarke, A., Sorgenfrei, M., Mulcahy, J., Davie, P., Friedrich, C. & McBride, T. (2021). Adolescent mental health: A systematic review on the effectiveness of school-based interventions. Early Intervention Foundation.
Other references
Department of Health and Department for Education. (2017). Transforming children and young people’s mental health provision: a green paper.
Fazel, M., Hoagwood, K., Stephan, S., & Ford, T. (2014). Mental health interventions in schools in high-income countries. The Lancet Psychiatry, 1(5), 377–387.
Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., … UnUtzer, J. (2018). The Lancet Commission on global mental health and sustainable development. Lancet (London, England). doi:10.1016/s0140-6736(18)31612-x
Sadler K, Vizard T, Ford T, Marcheselli F et al. (2018). Mental Health of Children and Young People in England, 2020. NHS Digital.
Vizard T, Sadler K, Ford T, Newlove-Delgado T et al. (2020). Mental Health of Children and Young People in England, 2020. NHS Digital.
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