Introduction
Mental health promotion and prevention: operational definitions
Mental health promotion in schools
-
Inclusive approach.
-
Build programmes responsive to student, school and community needs, building connections between resources.
-
Focus on reducing barriers to student learning through programmes, based on evidence.
-
Emphasise and provide support for systematic quality assessment and improvement.
-
Ensure staff are engaged and supported.
-
Ensure efforts are sensitive to developmental and diversity factors of students.
-
Build interdisciplinary relationships in schools, strong teams and coordinating mechanisms.
Whole-school approaches
-
lack of adequate support (in terms of staff willingness and/or funding)
-
clarity operationalisation, and consistency in terminology used (this would also need to consider how mental health and illness are conceptualised)
-
having appropriately trained staff to provide support and supervision, and
-
engaging young people in the development of the promotion of positive mental health.
Focus and aims of the review
Methods
Inclusion and exclusion criteria
Search strategy
Results
References | Country of research | Methodology and study design | Sample and sample size | Theory | Intervention and its nature | Analysis, outcome and effect size |
---|---|---|---|---|---|---|
Neilsen et al. [32] | Denmark | Quantitative—intervention evaluated through pre- and post- intervention questionnaire—given to children, answered during school lesson time A process evaluation was also conducted. The intervention was not considered mature enough for a rigorous design, and thus there was no control group | Children in grades 5–9 aged 11–15 (Nt1 = 589, 53.8% male, 46.2% female; Nt2 = 532, 53.4% male, 46.6% female) Children from two public metropolitan schools Response rate was 96.2% pre-intervention and 83.9% post intervention. Thus, 532 children were included All participants received the intervention | Whole-school approach and Action competence (linking democracy and participation and empowerment) (see Clift and Jensen, [7]). Also, linked whole-school approach to health promoting schools framework | ‘Up’—measuring social and emotional competence—promoting mental health using a whole school-approach. Materials were tailored for knowledge, skills, meaning and social action. Aims to reduce socioeconomic inequality in social and emotional competence It has four components; Activities for children; Development of staff skills; Involvement of parents; Initiatives in the everyday life of schools Education materials were tailored to age groups and so they could be integrated into the curriculum Intervention process evaluation was also conducted assessing facilitating factors and barriers to implementation | Contingency tables with Chi-Squared tests (Sig. level 0.05) were used for the analysis. Statistically significant change of children reporting high social and emotional competence from before the intervention (33.3%) to after the intervention (40.8%) No effect size was reported |
Franz and Paulus [17] | Germany | Quantitative—pre and post questionnaire + interviews with staff Used a pre–post cohort comparison intervention design (entire cohort received the intervention and was compared to a subsequent cohort without the intervention a year later) | Questionnaires with 32 schools (Nteachers = 633) (Nt1 = 407, Nt2 = 226) and Nstudents = 4019 (Nt1 = 2201, Nt2 = 1818) aged 10–15 years Follow-up 12 months after the intervention | Resource -based conceptual theory, balancing internal and external needs and resources (see Becker, [4]) | MindMatters—an Australian programme for mental health promotion in adolescents—encourages respect and tolerance and involves a range of school personnel and children—also encourages resilience The German adaptation involves all involved in the school environment; children, teachers, parents, and so on. It translated the Australian version and parts were culturally adapted It encourages communication and problem-solving Prior to the trial, staff took part in training No intervention fidelity assessment was reported | Authors do not report the group comparison analyses they undertook. Some changes in positive mental health, some improvement in social competence are reported Authors describe effects as minimal (the highest degree of effect (delta) as highest 0.27 for scholastic contribution to social competence) |
Kimber et al. [29] | Sweden | Quantitative mixed between-within questionnaire design in RCT setting with 5 yearly assessments | Intervention evaluation focuses on 4 schools—2 SET and 2 non-SET schools (matched in terms of location, SES, demographics, and baseline measures) In SET schools all grades (4–9) received the intervention Sample for evaluation at each time point was aggregated across all groups with the same length of intervention received. Total NSET = 1857; total NNo−SET = 598 | No theory discussed | Social and emotional training (SET)—educational techniques This was delivered by class teachers during school hours SET covers, self-awareness, managing emotions, empathy, motivation and social competence Teachers were trained before the intervention and were provided with supervision Intervention fidelity assessment was not reported | Statistical analyses involved: (i) linear regression of each outcome on time in intervention by groups; (ii) Between group effect sizes for DVs (Becker’s delta) (iii) ANOVA/MANOVA for subscales for intervention and non-intervention groups taking into account gender Favourable results over 3 years—(i) Positive outcomes on 5 out of 7 variables—self-report internalising, self-report externalising, mastery, ‘I Think I Am’ and contentment in school. (ii) For the five significant variables, effect sizes were small (0.07) to medium (0.60). (iii) significant interactions between SET and no-SET schools on all but one outcome variables across 5 years (particularly externalising and internalising behaviours) Bullying levels remained consistently low in these schools compared to non-SET schools |
Dix et al. [11] | Australia | Quantitative—questionnaires for teachers and parents—Measures of KidsMatter implementation index; socioeconomic, academic performance All students in school received the intervention. Evaluation was conducted on a selected sample in each school. Study lasted 2 years | 100 primary(elementary) schools selected form 260 A random stratified sample of children 9.6 (SD = 1.6) years of age with up to 76 students in each school selected. NT1students = 4980. Overall 70% response rate for teachers and parents of these students. Nteachers = 1393 (15.1 years average teaching experience; 85% female). Families were 83% two-parent and 17% one-parent | Whole-school approach; uses a four-part conceptual framework, (1) positive school community, (2) social and emotional learning for children, (3) parent support and education, and (4) early intervention | KidsMatter trial Initiative focused on social and emotional competency Designed to improve mental health, reduce mental health problems, and provide greater support for children with conditions Implementation index was used successfully across participating schools. Schools were categorised into Low, Medium–Low, Medium–High, and High implementing groups and these were accounted for in analysis | Significant results using two-level Hierarchical Linear Modelling analysis of school-level characteristics and academic outcomes. Over 2 years, a 14% shift in teachers’ views that the intervention had led to improvement on academic performance |
Fitzpatrick et al. [16] | Ireland | Quantitative—including measures on SDQ, coping strategy checklist, and non-standard measures of help-seeking and ‘what school is like’ Three-year programme A cluster sample-based randomised control trial was used Comparison of standard and enhanced programme | 44 primary schools where training had been given to teachers were contacted—31 expressed interest and 17 participated − 1072 students aged 12–16 years took part. Of these, 53% were male, 47% female Stratified for school type, and schools were randomly allocated to standard or enhanced programme | Whole-school approach | Enhanced Social, Personal and Health Education Programme including a mental health component—measured against the standard programme ‘Working things out programme’ based on guidance of children with mental disorders to be used for universal promotion DVD intervention, with support of mental health professionals. On the DVD young people told their stories. These were used to develop the enhanced programme. Intervention fidelity assessment was not reported | A series of factorial ANOVAS looked at effects of time in intervention, condition, gender, and caseness on mental health outcomes. Few differences over time between the two programmes. One statistically significant difference in terms of help-seeking, students showed greater improvement in the enhanced programme in terms of a reduction of peer problems No effect sizes were reported |
Anthony and McLean. [1] | Australia | Quantitative—self report surveys to measure protective factors of resilience—completed by children and their class teacher Measures of protective factors, social validity included | 39 children aged 8–10 from 2 medium sized suburban primary schools, 15 males, 24 females (mean age, 9.17) 17 were given intervention and 22 control group 1 school was the intervention group, the other a comparison group | Universal approach to promotion | BounceBack intervention—whole school-based resiliency programme, promoting resilience, and positive mental health by teaching social and emotional competencies and positive psychology (see McGrath and Noble, 2003) Intervention enhances protective factors associated with resilience Is a year-long, multi-year programme Consisted of 9 1-h sessions over 9 weeks No training was provided to the teachers or the researchers running the study Intervention fidelity assessment was not reported | Mixed between-within ANOVA assessed change across two time periods in two groups on selected outcomes. One-way repeated measures ANOVA assessed change over time. Overall effectiveness of BounceBack found. Children reported higher levels of resilience post intervention than control (for example, large effect size for recourse index, moderate for vulnerability index). Impact of intervention was maintained at 3-month follow-up |
Haraldsson et al. [22] | Sweden | Quantitative—interventional and evaluative pre- and post-test design | Two secondary schools—children aged 12–15 years (6–8 class) Intervention group (school 1) = 153 (90 male, 63 female) Non-intervention (school 2) = 287 (142 male, 145 female) No health promotion had been given previously in these schools Children of similar socio-economic background in each group. Pre- and post-questionnaires were administered at the start and end of academic year | No theoretical framework discussed | Health promotion programme—used as a regular school subject each week for one academic year (25–30 lessons in total). Stress intervention administered by physiotherapist who had experience of stress management Data collected at start and end of school year Intervention fidelity assessment not reported | At baseline no statically significant difference between two groups (using Chi square, t test, and Mann–Whitney U test). Wilcoxon Signed-rank test was used to compare within groups across times. Those with the stress intervention maintained their sense of wellbeing—non-intervention deteriorated. In both genders No statically significant difference between groups in terms of self-reliance |
Butzer et al. [6] | USA | Qualitative (but part of a larger mixed methods) The larger study randomly allocated students to the intervention or control Randomly selected for interview Grounded theory | 404 students were enrolled onto the school curriculum Grades 7–12 16 students interviewed, 8 males and 8 females, majority were white Focus of the interviews was on feasibility of yoga and their experience of it. Interviewers were trained in interviewing skills Multiple coders ensured coding reliability | Grounded theory framework—little discussion of theory | Yoga for 7th grade children (aged 12–13 years). Including mindfulness and meditation. Focus on stress management, emotional regulation, confidence building, and promoting peer relationships Yoga sessions were 35 min long and delivered 1–2 times per week It was integrated into the Physical Education curriculum Looked at qualitative differences between phenomenological experiences Intervention fidelity assessment not reported | 44% had a positive view of the class, 25% had negative and the rest mixed 69% felt it helped raise mood and manage stress 62% felt it had a positive effect on sleep 25% felt a positive effect on academic performance |
Lendrum et al. [31] | United Kingdom | Qualitative—Multiple case study design Interviews and observations which were semi-structured. Interview schedules were informed by the literature and modified in accordance with the approach | National—schools—all 300 secondary schools using the SEAL intervention were invited 48 said yes and 10 were included, but one dropped out, resulting in 9 Schools from 7 local authorities participated to ensure geographical spread Sampling strategy was purposeful | No specific theory identified (but there was some discussion of the whole school approach) | SEAL for adolescents—a social and emotional intervention—whole-school approach—Schools visited once per term over 5 terms Intervention fidelity assessment for SEAL implementation was conducted | Use of NVivo facilitated coding Validity and reliability were supported by triangulation They created a thematic framework. This showed that there was no reported impact on outcomes in social and emotional skills, behaviour or mental health difficulties They showed that there is a need for greater awareness of emotional health and wellbeing in schools. Staff need to be better supported and increase their skills |
Hall [21] | United Kingdom | Qualitative—focus groups—educational psychologists working with schools | 18 children participated Four focus groups were conducted All children were from reception year (aged 3–5 years) to year 6 (aged 10–11 years) Children were selected by school staff | Child centred framework—children’s rights—creating an environment to foster positive mental health | Ten Element Map—framework and model to promote mental health to identify what works for children in terms of environment, self-esteem, emotional processing, self-management and social participation—used as a tool to elicit children’s perspectives | Positive results, as the framework enabled the identification of children’s mental health skills—whole-school approach effective. A useful framework for accessing children’s voices on the matter Concludes—a useful tool for to promote mental health in schools |
Theoretical frameworks
Support, training, and supervision of staff
Mental health outcomes
Long-term impact
Overall results
Discussion
Challenges of using interventions
Strengths and limitations
Directions for future research
-
A sound theoretical base with specific, well-defined goals that were communicated effectively.
-
Focus on the desired outcomes.
-
Explicit guidelines and through training, which is quality assured.
-
Complete and accurate implementation.