A recent review published in Child and Adolescent Mental Health explores what factors make school-based psychological interventions successful. The research, conducted by Brioney Gee of the University of East Anglia and her colleagues, sheds light on what schools can do to best support student’s mental health in the wake of the COVID-19 pandemic closures. Their results suggest that the inclusion of students in the development of these initiatives is essential to their success.
Widespread efforts to reduce the spread of COVID-19 may be exacerbating significant issues (e.g., food insecurity, social isolation, and anxiety) that had already impacted student well-being pre-pandemic. Although the rationale driving measures such as school closures and business shutdowns has been well-documented, some of the side-effects of these initiatives are likely to extend well beyond the duration of these precautions themselves.
When students begin returning to classrooms, after social distancing measures are stepped down, schools will likely be looking for health and well-being programs that can successfully meet their needs. Gee and colleagues’ research speaks to the importance of using collaborative and inclusive processes when developing these programs.
The researchers scoured fifty articles describing school-based interventions targeting “emotional disorders” in high-income countries for commonalities, establishing themes including a variety of facilitators and barriers to the successful implementation of initiatives. Their results indicate that a truly successful implementation of school-based initiatives to promote mental health is complicated. However, the integration of both student and education professional voices in the design/selection process can go far in making these efforts acceptable and practical.
The researchers found that school administrators are often instrumental in promoting the success of school-based programs by cultivating a supportive school culture and championing initiatives to reduce psychological distress among students. Both the staff implementing interventions to support student mental health as well as those responsible for referring students for intervention require thorough and continued professional development to ensure quality services for students.
According to authors, emotional disorders (e.g., anxiety, mood disorders, and post-traumatic stress) have increased among adolescents at a higher rate in the UK than behavioral disorders (where the study was conducted). Efforts are underway in the UK to scale up school-based mental health services, and implementation fidelity (the extent to which an intervention is implemented as intended) is thought to be a crucial component of intervention success.
Establishing whether an intervention is successful in facilitating its intended effects is not possible without evidence of successful implementation. Thus, Gee and team emphasize the importance of establishing the conditions that foster implementation success.
To “maximize the relevance” of their search to recent developments in UK school policy, authors focused their systematic review on publications detailing “indicated interventions” – that is, interventions provided to a subset of students out of the general student population identified as experiencing symptoms of distress or disorder. Their focus on interventions targeting emotional disorders identified in schools, and inclusion of studies limited to high-income countries, was also to promote relevance to recent trends and areas of need for research in the UK.
Studies including samples of students aged 10 to 19 identified as experiencing elevated psychological distress or impairment were included in the review. Studies included were also required to comprise school-based, theory-informed psychological interventions delivered in completion, and publications needed to report information on facilitators and barriers to intervention implementation.
This study was thus not about reviewing the effects of interventions on reducing the severity of distress, but rather on evaluating processes in implementing indicated, school-based mental health initiatives for students ten and older. All of the 50 studies that met inclusion criteria were conducted between 1998 and 2018 and most outlined interventions to target depression or anxiety. Of note, no studies including students 12th grade (sixth form in the UK) or above satisfied met standards for this review.
The authors identified eleven analytic themes across articles reviewed. They nested these themes into umbrella categories, including intervention characteristics, organizational capacity, training and technical assistance, provider characteristics, and community-level characteristics.
Their model for understanding facilitators and barriers to successful implementation represents an ecological framework with an appreciation for diverse contextual factors beyond student and interventionist characteristics alone. They emphasize the complexity and overlapping systems impacting intervention quality.
“There is a danger that the creation of new school-based services will add further silos to an already complex and fragmented system. We must avoid this and instead use these developments as an opportunity for greater joint working and system alignment.”
The global psychosocial landscape is likely to have changed in significant ways in the short time since the design and implementation of Gee and colleagues’ study. However, many of the findings and implications for practice offered in this review point to ingredients fundamental to the success of school-based mental health initiatives.
Schools must adapt the models they had previously applied to create space for innovative strategies to reach students and evolve as the crisis develops. Gee and the team’s recommendations to involve young people and educational professionals in intervention development and their emphasis on administrator investment are likely to translate whatever the intervention modality (e.g., online through school versus in-person through school).
Today’s students are grappling with unexpected adjustment, loss, uncertainty, and a gamut of diverse emotions associated with COVID-19 on a global scale. Education systems could contribute to student well-being not by pathologizing distress, but by providing supports to reduce distress and make the day-to-day a little more comfortable and tolerable.
Pre-pandemic research documented increased experiences of anxiety and depression among students fueled by complex environmental determinants. With the current, far-reaching safety measures posing pronounced difficulties for students and their families during the global pandemic, this research may be valuable as schools consider how to adjust meet students’ needs. The authors conclude:
“Those involved in the implementation of school-based mental health interventions should ensure they select appropriate interventions, consider logistical challenges, and provide high-quality training and supervision to enable staff to deliver interventions with fidelity. Further, it is important to consider the structural and environmental support required for successful implementation to ensure potential benefits are maximized.”
Gee, B., Wilson, J., Clarke, T., Farthing, S., Carroll, B., Jackson, C., … Notley, C. (2020). Review: Delivering mental health support within schools and colleges – a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents. Child and Adolescent Mental Health. Doi: 10.1111/camh.12381 (Link)