School-based indicated promotion and early intervention

Anxiety management/relaxation training and interpersonal approaches also appear to be promising elements in school-based interventions, particularly for young people with co-morbid symptoms of depression and anxiety (Collins & Dozois, 2008;

Greenberg et al., 2001). However, a large-scale evaluation of the Problem Solving for Life Program, implemented in Australia by teachers with Year 9 students (mean age 14.34 years), failed to find positive outcomes even at post-test (Sheffield et al., 2006).

No significant differences between the intervention and control students were found in terms of changes in depression, anxiety, coping skills or social adjustment over time from: baseline to post-intervention; three-month; and 15-month follow-up.

Students with poorer mental health, including elevated symptoms of depression at pre-intervention showed a gradual reduction in poor mental health symptoms over time, irrespective of intervention (Sheffield et al., 2006). The study’s reliance on student self-reporting and a relatively low participation rate, together with the limited hours of teacher training, with regards to programme delivery, and fidelity of teacher observations, were among the limitations noted by Spence and Shortt (2007).

Research has nevertheless also documented significant strengths, including a large sample size, a low attrition rate and the fact that the schools were broadly representative of the general population (Spence & Shortt, 2007). Pattison and Lynd-Stevenson (2001) also conducted primary research of mental health in schools.

Similar to findings reported by Sheffield et al. (2006), they found no significant difference between boys or girls on poor mental health knowledge, treatment seeking or attitudes about poor mental health (i.e., improvement in functioning).

Clarke et al. (1995) describe some positive short-term results from a health promotion programme, which focused on reducing the prevalence of affective disorders and targeted high school adolescent students (mean age 15.49 years) with poor mental health symptoms. Adapted from the Coping with Depression Course (Lewinsohn, Antonuccio, Steinmetz & Teri, 1984), which taught cognitive restructuring and problem-solving skills, Clarke and colleagues (1995) administered the indicated promotion programmes to Year 9 and 10 students (n=150, mean age=15.3). The programme was delivered in a small group format (six to ten adolescents) for a total of 15 sessions over five weeks. At 12-month follow-up, the incidence of major

depression in the intervention group (15%) was half that in the control group (26%).

Although criticised for being self-selected, the study represents the first published report of prevention of a mental health disorder in a child and youth population (Barrett & Turner, 2004).

In a similar way, Lamb, Puskar, Sereika and Corcoran (1998) implemented a cognitive skills prevention programme in the US for rural high school students (n=41, ages 14 to 19 years). The researchers found a moderate treatment effect size of 0.70 at post-intervention. Likewise, Klingman and Hochdorf (1993) conducted research on 237 Grade 8 students, aged 12 to 13, who were randomly assigned to treatment and control groups within classrooms. After 12 sessions over 12 weeks of primary prevention programmes on skills coping with distress and self-harm, students in the treatment group displayed a lower risk of potential suicide, demonstrated more positive coping skills, and obtained significantly more knowledge of suicide facts and help resources than students in the control group. Conversely, in a randomised controlled trial in rural Australia, Roberts et al. (2003) found no significant differences in depressive symptoms between groups immediately after intervention or at follow-up. However, the intervention group reported less anxiety and a more optimistic explanatory style. Results of poor mental health and wellbeing interventions have generally yielded only small to moderate effect sizes thus far and many findings still need to be replicated (Collins & Dozois, 2008).

Few prevention studies have examined the benefits of including a parent or family component in school-based interventions (Stice et al., 2009). In Australia, Shochet et al. (2001) examined the efficacy of the RAP, an approach derived from cognitive-behavioural and interpersonal psychotherapies. Shochet et al. (2001) reported on an Australian high school cohort (n=260, aged 14 to 15). In the first cohort, mental health problems in Year 9 students were measured on three occasions over 15 months.

In the second year, those in the next cohort were similarly measured, but received an 11-session small group programme, largely modelled on the cognitive therapy approaches of Clarke et al. (1995). In comparison to controls, both intervention groups demonstrated significantly greater reductions in poor mental health symptoms at post-test, with students who entered the programmes with moderately elevated (subclinical) poor mental health scores seeing the greatest improvement. Overall,

adolescents reported lower levels of poor mental health on one of two measures at post-intervention and 10-month follow-up.

Shochet et al. (2001) note that the addition of the parent component did not add significantly to the effects of the adolescent programme. The attendance rate for parents in the family condition (three parent sessions) was extremely low, with only 36% of adolescents having a parent who attended at least one of the parent sessions, and only 10% having a parent who attended all three (Shochet et al., 2001). This study was limited by the use of a single school, non-random assignment to experimental conditions, potential cohort effects, differential assessment periods across experimental conditions, and small sample size (Spence & Shortt, 2007).

Evidence to support the benefits of including a parent intervention for the prevention of depression was found by Gillham, Reivich et al. (2006) in the US. A six-session parent component to the PRP was incorporated for a small sample of ‘at-risk’ children (n=44). Significant reductions in the adolescents’ symptoms of depression over the one-year follow-up period were found when compared to controls (ES=–0.45). In the study Clarke et al. (2001) conducted in US, in which the authors included three parent education sessions in the control trial of the Coping With Stress Course, and was in comparison to their earlier trial that did not provide any parent component (Clarke et al., 1995), the experimental group to some extent yielded a stronger treatment effect size post-intervention (ES=0.41 versus ES=0.31) and a lower incidence rate (9%

versus 15%). Positive results were maintained at 15-month post-intervention in the 2001 trial, whereas differences were not observed at the six-month and 12-month follow-up points in the 1995 trial (Clarke et al., 1995; Clarke et al., 2001). Clarke et al. (1995) found that a 15 session group cognitive-behavioural intervention resulted in greater reductions in poor mental health symptoms by post-test than an assessment-only control condition for adolescents with poor mental health symptoms, with affective disorder total incidence rates of 15% for the active intervention and 26% for the control condition; however, this effect was non-significant at 12-month follow-up.

Stice et al. (2009) noted that even though the specific variables for the results in such studies were not identified, the inclusion of parents in prevention programmes is an exciting new direction for interventions.

3.1.2.3 School-based selective promotion and early intervention programmes for mental health and wellbeing

Cardemil et al. (2002) reported the results of two school-based trials of a modified version of the PRP conducted in the US, with markedly different effects in the two samples. In their first study, Cardemil et al. (2002) modified the PRP for implementation with low-income children of Latino ethnic descent (n=49; mean age=11.3 years). A large treatment effect was found post-intervention (ES=0.99), which increased at the six-month follow-up point (ES=1.24). Beneficial effects encompassing depressive symptoms, negative cognitions and self-esteem were also seen over six months of follow-up. A second study also conducted in the US (Cardemil et al., 2002), using an indicated sample of predominantly African-American children (n=106; mean age=10.9 years), failed to obtain a preventative effect. However, the follow-up period was limited to six months and the sample sizes were small, particularly in the Latino group (Spence & Shortt, 2007). Findings in the two-year post-intervention of this study showed that the PRP continued to have significant benefits on depressive symptoms and negative cognitions for the Latino children, but no significant effects for the African-American children (Cardemil et al., 2007). Cardemil et al. (2007) found that children in the prevention group reported significantly fewer depressive symptoms and a more optimistic explanatory style than did controls immediately following the intervention.

Further, Sturm, Ringel and Andreyeva (2003) illustrate the importance of understanding factors that influence mental health and wellbeing in the pursuit of school-based mental health and wellbeing promotion programmes. They examined the geographic variation in unmet need for school-based mental health services among young people. The integral role that schools can play in the delivery of coping skills to low-income, racial/ethnic minority young people can also be an outcome of this research. Since many parents of low-income, racial/ethnic minority young people may be less likely to utilise formal mental health services (Meredith et al., 2009; Stephan, Weist, Kataoka, Adelsheim & Mills, 2007), schools and school-based selective programmes play an important role in the promotion of positive mental health and in the prevention of mental health issues among adolescents.