First Systematic Review of Leading School-Based Mental Health Programs

A new study published in the Harvard Review of Psychiatry presents the first systematic review and comparison of school-based mental health programs. The authors, J. Michael Murphy, Madelaine Abel, Sharon Hoover, Michael Jellinek, and Mina Fazel, investigated the defining characteristics and strengths of such programs in low- and middle-income countries (LMICs) excluded from prior literature. Results reflect moderate to strong evidence in support of the non-pharmacological school-based interventions reviewed in the study, all of which been shown to have a meaningful, positive impact on mental health and often academic outcomes.

“Over past few years, the scale and scope of children’s mental health programs have increased considerably, now reaching whole districts, counties, states, provinces, and even whole countries with tens of millions of children involved,” the researchers write. “The establishment of large-scale programs in real-world settings has also created new opportunities for cross-program comparisons, continuous quality improvement, and possibly, soon, the evaluation of population-scale improvements.”

Recent years have seen widespread, international acknowledgement of the expense, both psychological and monetary, of reactive support for mental health concerns among students. The authors note that many debilitating and resource-consuming mental health conditions experienced by adults may emerge in childhood and that preventative programs are being developed and employed in schools worldwide.

An increase in in-school proactive measures has been reflected in international efforts towards multitiered systems of support (MTSS). Individual school-based mental health programs designed to support all students have been subjected to empirical evaluation, some through randomized controlled trials and some through quasi-experimental examination.

The authors began their investigation by pinpointing leading school-based mental health programs through comprehensive literature review comprised of a search of relevant key terms on MEDLINE and PsycINFO, and consideration to reference lists within articles found that had reviewed substantial programs. This process yielded eight programs satisfying inclusion criteria.

The programs selected for their review included: Positive Behavior Interventions & Supports (PBIS), FRIENDS, Positive Action (PA), Promoting Alternative Thinking Strategies (PATHS), Skills for Life (SFL), MindMatters, Good Behavior Game (GBG), and Cognitive-Behavioral Interventions for Trauma in Schools (CBITS). All of these programs have all undergone empirical scrutiny, have operated for more than ten years, and have reached a combined total of over 27 million children to date.

Only one of the programs reviewed, SFL (designed and operated in Chile), was developed in a LMIC. This is an important finding in itself, the authors explain, given that:

“Until recently, widely scaled preventive mental health interventions for children have been studied almost exclusively in [high-income countries] HICs, even though about 80% of the global population of children reside in LMICs.”

Intervention categorizations were compared across programs, specifically addressing qualities according to the following domains: Tier 1, provision of preventative mental health-oriented supports to all students in a population regardless of prequalification; Tier 2, mental health services provided to a targeted group of students identified as vulnerable; and Tier 3, individualized mental health services provided to specific students.

The authors established conceptual and practical histories of programs selected through phone interviews with researchers that had played an important role in the development of each program. With emphasis on Tier 1 and 2 supports (distinct from treatment) to students within each program, scope (characteristics of the program and populations served), scale (growth and magnitude of the program in its entirety), and dose (time and personnel program components) were assessed.

Their results indicate that, in relation to scope, all but one program assessed (CBITS) provide Tier 1 support to students.

• Six of the programs are classroom-based and implemented by teachers, and only two require intervention by mental health professionals occurring outside of a school’s existing curriculum. Format of interventions varied across programs according to their respective designs and objectives.
• PBIS was found to be the largest program in scale, although rough approximation of reach was necessary due to evolution of various permutations of its original design.
• FRIENDS, PA, PATHS, and SFL were found to reach a million or more children each.
• FRIENDS, SFL, and MindMatters have achieved national implementation; FRIENDS boasting the largest international presence with representation in 12 countries.
• SFL, provided by the Chilean department of education, is available to schools across the country’s 15 regions.

According to the authors, “[SFL] targets schools with high levels of poverty and other indicators of social risk.” Only three of the programs included in this review have been implemented to scale in LMICs, including FRIENDS, SFL, and GBG.

The researchers note challenges in cross-comparing the dosages of care, explaining that some interventions (six, within this review) occur separate from typical school activities and can thus be quantified, while some (two, within this review) are continuous and integrated into school curriculum.

The dosage of care within the SFL program is clearly delineated across tiers of support, as well as within CBITS, while in PBIS and MindMatters dosage is contingent upon factors varying across classrooms and settings. The study highlighted PA and PATHS as intensive in relation to less comprehensive, but equally structured programs such as FRIENDS and GBG.

Methodological limitations include reliance on interviews with program experts for descriptions of leading in-school mental health services (potential for human error), and differences in units of intervention making cross-comparison challenging. It is also important to bear in mind that programs targeting social-emotional learning were excluded from this review, as they have not been explicitly linked to mental health outcomes.

The expansion of school-based mental health programming throughout the world offers the opportunity for future cross-comparison, and potential application of versatile, empirically supported programs to LMICs. In summary, authors state:

“[T]his review provides evidence that large-scale, school-based programs can be implemented in a variety of diverse cultures and educational models as well as preliminary evidence that such programs have significant, measurable positive effects on students’ emotional, behavioral, and academic outcomes.”

This study indicates promise in much of what is already being done in certain schools to support student mental health, and provides direction for future investigation. Murphy and colleagues shed light on the potential utility of preventative programming in schools, particularly in LMICs, as a public health objective with implications for mental health throughout the lifespan.

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Murphy, J. M., Abel, M. R., Hoover, S., Jellinek, M., & Fazel, M. (2017). Scope, scale, and dose of the world’s largest school-based mental health programs. Harvard Review of Psychiatry, 25(5), 218-228. (Link)