School-based universal promotion and early intervention

Universal prevention efforts for poor mental health that have been based on interpersonal psychotherapy, CBT⁹ or interpersonal-based approaches have had some promising results (see Christner, Mennuti & Pearson, 2009; Collins & Dozois, 2008;

Stice et al., 2009). Among adolescents, the emphasis of universal strategies has shifted towards promoting positive school environments and reducing exposure to alcohol and other neurotoxic substances (Hickie & Walter, 2009; Patton, Bond, Butler

& Glover, 2003).

In terms of school-based mental health and wellbeing promotion programmes, CBT is the most researched and benefits the most from the strongest empirical support with respect to effect size and maintenance of intervention gains (Horowitz & Garber, 2006; Jane-Llopis, Hosman, Jenkins & Anderson, 2003; Stice et al., 2009), and in highlighting the importance of cognitive factors in the aetiology of mental health problems (Collins & Dozois, 2008). This is consistent with recent child and adolescent mental health literature focusing on approaches that incorporate the inclusion of building psychological wellness in youth (Doll, 2008; Suldo & Shaffer, 2008).

Benefits derived from the widespread use of CBT techniques in universal interventions have been shown to be an effective means for reducing mental health and wellbeing problems, such as anxiety, among young people (Attwood, Meadows, Stallard & Richardson, 2012; Davis, May & Whiting, 2011). However, the extent to

9 The premise of cognitive theories of emotional disorder is that dysfunction arises from individualised interpretation of events, with behavioural responses emerging from those interpretations being potential influences of emotional problems (James, Soler & Weatherall, 2013; Wells, 1997). Self-control strategies, and in particular self-observation, self-modification, self-evaluation and self-reward, are the most common cognitive strategies used (James et al., 2013). CBT appears equally effective in various formats and settings including in schools (see Galla et al., 2012; Ginsburg, Becker, Drazdowski &

Tein, 2012; Ginsburg & Drake, 2002).

which it is equally effective for different age groups, and in particular for the early adolescent period, have yet to be clearly demonstrated (Cartwright-Hatton, McNicol

& Doubleday, 2006; Spence, Burns et al., 2005). Nevertheless, studies have highlighted the potential effectiveness of CBT approaches used specifically in a school setting (Christner, Forrest, Morley & Weinstein, 2007; Collins et al., 2013;

Mennuti et al., 2006; Ollendick & King, 2004). Further, components of CBT parallel many of the existing services in schools (Christner, Mennuti & Pearson, 2009), potentially making it easier for educators to implement mental health interventions with CBT components (Christner, Mennuti & Stewart-Allen, 2004; Collins et al., 2013; Mennuti & Christner, 2005; Mennuti et al., 2006). Such interventions are not personnel- or time-exhaustive, and so are thought to be more likely to be sustained by schools (Fridrici & Lohaus, 2009; Han & Weiss, 2005).

CBT interventions in schools have included variations, using different types of cognitive and behavioural components, having various levels of effectiveness. School cognitive-behavioural interventions have significantly reduced the risk for future onset of major mental health problems in some trials (Clarke et al., 1995; Clarke et al., 2001), but not in others (e.g., Gillham, Reivich et al., 2006; Sheffield et al., 2006).

The first published, large-scale evaluations of universal, school-based prevention of mental health problems were documented in a US study by Clarke et al. (1993). In their first trial, 361 youths were randomly allocated to an intervention or a control condition. Participants were also encouraged to seek further intervention if required.

The intervention failed to produce significant effects upon depressive symptoms compared to students in the control group, resulting in the development of an expanded programme that included problem-solving skills training. The expanded intervention consisting of a five-session behavioural skills training intervention also failed to produce any appreciable changes in depressive symptoms across conditions or across time. One of the studies found a short-term reduction in depressive symptoms among boys, but not among girls, when compared to a randomly assigned control group. The effect was not sustained at the 12-week follow-up (Clarke et al., 1993). The second study similarly failed to demonstrate any differences for either gender, immediately after the programmes or at follow-up, compared to a random control condition (Clarke et al., 1993). Gillham et al. (2000) speculate, however, that

the interventions in these studies could have been too weak and brief to produce an effect.

In the US, using a universal prevention trial for mental health issues with adolescents (N=380), Horowitz et al. (2007) similarly evaluated the efficacy of two programmes, an interpersonal psychotherapy–adolescent skills training (IPT-AST) and a cognitive-behavioural intervention. Participants in both interventions reported fewer depressive symptoms post-intervention than individuals in the control group; however, results were not maintained at the six-month follow-up. Horowitz et al. (2007) further evaluated the results among a sub-sample of high-risk adolescents (n=96) and found larger treatment effects post-intervention for both CBT (ES=0.89) and IPT-AST (ES=0.84) compared with the larger sample (ES=0.37 and 0.26 respectively). Pössel, Horn, Groen and Hautzinger (2004) also examined the effects of a school-based intervention, which included cognitive restructuring, assertiveness and social competence training.

Using this cognitive-behavioural approach to prevention of mental health issues in the US, Pössel et al. (2004) documented significantly different patterns of results for students at different levels of risk. While they report that the groups did not differ with regard to their social skills; frequency of negative automatic thoughts; and depressive symptoms before the prevention programmes; there were no significant differences in self-reported depressive symptoms between training and control groups.

Significantly lower rates of increase in depression symptoms following participation in the intervention were reported for those with minimal levels of depressive symptoms at pre-test, compared to no-intervention controls over the 6 month follow-up period. A significant decrease in depression scores after intervention were exhibited by students who initially reported sub-syndrome depression scores or who initially showed depression scores in the clinical range, while the control group continued to show higher incidence of depressive symptoms (Pössel et al., 2004). The percentage of adolescents in the training group with sub-syndrome depression decreased from 52% to 31% compared with the control group (50% versus 51%) over the 6 month follow-up (Pössel et al., 2004). Students who were low in self-efficacy benefited more from the programmes than high-self-efficacy students (Pössel, Baldus, Horn, Groen & Hautzinger, 2005).

Results of programmes with adolescents suggest that cognitive, parent/family, and school interventions are potential intermediaries of prevention outcomes for mental health prevention (Stice et al., 2009). The majority of interventions targeting young people, however, have utilised the Penn Resiliency Programmes (PRP)¹⁰ or modified versions (Penn Optimism or Prevention Programmes), with positive results obtained (e.g., Cardemil, Reivich & Seligman, 2002; Gillham et al., 2007; Gillham, Reivich et al., 2006; Gillham, Reivich, Jaycox & Seligman, 1995; Jaycox, Reivich, Gillham &

Seligman, 1994). The PRP has also been shown to be a low-cost, short-term intervention that is able to provide a particular benefit to mildly symptomatic young people in years 5 to 8 (Cardemil, Reivich, Beevers, Seligman & James, 2007).

Randomised controlled trials of the PRP and Penn Enhancement Programmes (PEP)¹¹ with adolescents exhibiting higher levels of mental health symptoms, were conducted in schools in the US by Gillham et al. (2007). In this study a large sample of young people aged 12 to 13 years were recruited (n=697, years 6 to 8) from three high schools in the USA and were randomly assigned to one of two intervention groups (PRP or PEP) or to a control condition. Participating schools did not yield a significant treatment effect; however, significant results were obtained for the PRP in two of the schools across three years of follow-up. Specifically, the Resiliency Programmes were associated with improved mental health and wellbeing compared to both the Enhancement Programmes and the control condition, being attributed to the specific cognitive-behavioural intervention components (see Collins & Dozois, 2008).

Gillham and colleagues (2007) postulated, however, that problems with implementing the programmes in ‘real world’ settings may have partially accounted for the lack of significant findings (e.g., programme integrity).

Jaycox et al.’s (1994) findings of the Penn Optimism Programme in US schools was one of the first to demonstrate long-lasting intervention gains and true prevention

10 PRP is a school-based cognitive-behavioural intervention designed for youths in late childhood and early adolescence (ages 10 to 14 years) (Brunwasser, Gillham & Kim, 2009). The programme aims to teach the connection between life events, their beliefs about those events, and the emotional

consequences of their interpretations (Gladstone, Beardslee & O’Connor, 2011). Students learn techniques for assertiveness, negotiation, decision-making, social problem-solving and relaxation (Brunwasser et al., 2009; Gillham, Hamilton, Freres, Patton & Gallop, 2006; Gillham et al., 2007).

11 Identical to the Penn Prevention Program: Affect focused programme with emphasis on emotional expression (Horowitz & Garber, 2006).

effects. The programme was comprised of 12 group sessions, with cognitive (e.g., identifying, testing, and modifying negative thoughts) and social problem-solving skills (e.g., perspective taking) being taught. ‘At-risk’ young people (n=143; ages 10–

13 years) were screened for high levels of depressive symptoms and parental conflict.

Reductions in depressive symptoms were observed at post-intervention (ES=0.18) and at the six-month follow-up (ES=0.32). Results of an evaluation of CBT-based programmes targeting Chinese adolescents living in China with elevated depressive symptoms (Yu & Seligman, 2002) found that the intervention significantly reduced depressive symptoms over a six-month period. Gillham et al. (1995) found fewer young people in the prevention group demonstrated depressive symptomatology in the moderate to severe range (22%) compared with those in the control group (44%).

On the other hand, several studies of the PRP have failed to replicate the positive outcomes on mental health symptoms among young adolescents (Pattison & Lynd-Stevenson, 2001; Quayle, Dziurawiec, Roberts, Kane & Ebsworthy, 2001; Roberts et al., 2003). Pattison and Lynd-Stevenson (2001) evaluated the Penn Prevention Programmes (PPP), a similar cognitive-behavioural intervention that aims to enhance optimistic explanatory style, interpersonal problem-solving skills, assertiveness and social skills. The randomised controlled trial, conducted with years 5 and 6 students, aged between 9 and 12 years, at a rural primary school in Australia, failed to find group differences between the PPP and both a non-intervention and attention control group. The authors failed to find evidence that the programme had any impact upon depressive symptoms, anxiety symptoms, social skills or cognitive style. Further, they found no significant effects for depressive symptoms at post-test or six-month follow-up compared with active control and assessment-only control grofollow-ups (Pattison &

Lynd-Stevenson, 2001). Similarly Stice, Shaw and Marti (2006) did not find any substantial differential changes on level of mental health among five prevention interventions with adolescents (CBT, supportive-expressive, bibliotherapy, expressive writing or journaling). In their recent research, Stice et al. (2009) propose that the brief nature of the interventions provided in their earlier research (four sessions) probably limited detection of group treatment effects. In a review of school-based interventions, Spence and Shortt (2007) note that the design of the study used by Pattison and Lynd-Stevenson (2001) was limited by their use of a small sample size,

lack of random assignment for the no-intervention control group and low consent rates for participation.

A study conducted by Quayle et al. (2001) likewise piloted and evaluated the effects of a modified and shortened version of PPP (Aussie Optimism Program) with Grade 7 girls aged 11 to 12 years at an Australian private school. The groups did not differ significantly on any outcome variables at the post-test or six-month follow-up.

However, at the six-month follow-up the intervention group reported significantly fewer depressive symptoms and higher self-esteem than the control students (Quayle et al., 2001). The authors contributed this difference to a decrease in the self-worth of the control group at the six-month follow-up compared to the maintenance of self-worth in the intervention group.

O’Dea and Abraham (2000) conducted a controlled educational intervention to improve self-esteem in male and female adolescents for the purpose of reducing the risk of eating disorders and found improved self-esteem and body image as well as improvements in anxiety and depression. This self-esteem intervention was particularly important because it showed the greatest impact on those students who were most at risk of mental health issues. However, methodological limitations of this study included the low consent rate, small sample size, poor programme attendance rate, lack of representativeness of the sample and substantial loss of data at follow-up (Spence & Shortt, 2007).

Various school-based mental health promotion programmes have also included universal interventions with students with clinical diagnosis of mental health disorders being excluded (e.g., Gillham et al., 2007; Merry, McDowell, Wild, Bir & Cunliffe, 2004; Spence, Sheffield & Donovan, 2003; Spence, Sheffield & Donovan, 2005). In a randomised controlled trial of a universally delivered prevention programme (RAP-Kiwi) conducted in New Zealand schools, Merry et al. (2004) observed a significant post-intervention decrease in depression symptoms for RAP-Kiwi but not for the comparison group. Merry et al. (2004) evaluated teacher-delivered Resourceful Adolescent Programmes (RAP) in comparison to a placebo condition, with years 9 and 10 students, aged 13 to 14 years, in two New Zealand schools. The data were analysed using difference scores and indicated that, at post-test, the intervention students reported significantly greater levels of poor mental health on both measures

compared to the control group. Results were partially maintained over the 18-month follow-up period (Merry et al., 2004). However, Spence and Shortt (2007) note that the control intervention included some elements that had the potential to influence mental health and wellbeing, such as identifying pleasant activities, group problem solving and body language.

Spence et al. (2003) also evaluated the impact of a real world, universal, school-based approach to the prevention of mental health issues, with clinical diagnosis excluded, in Queensland, Australia. Unlike Merry et al. (2004), this study was a randomised controlled trial of a teacher-administered, classroom-based, universal intervention that aimed to teach a range of problem-solving and cognitive coping skills to 1500 students aged 12 to 14 years in 16 schools (Spence et al., 2003). High-symptom students in the intervention group showed a significantly greater decrease in poor mental health than high-symptom students in the control group. Equally, for students with low levels of baseline depression symptoms, the control group demonstrated a short-term increase in depression scores and a decrease in problem-solving skills, while the intervention condition demonstrated a slight decrease in depression scores and an increase in problem-solving ability immediately following the intervention (Spence et al., 2003).

At the 12-month follow-up the intervention effects were no longer evident. Spence, Sheffield et al. (2005) subsequently reported the two-, three- and four-year follow-up results of this study in order to determine if any delayed beneficial effects became evident as the students encountered the stressful life events of adolescence. Despite expectations, no significant differences in the trajectories of poor mental health symptoms were evident between the intervention and control conditions over the follow-up period (Spence, Sheffield et al., 2005). In an analysis of these studies, Spence and Shortt (2007) postulate that although Spence, Sheffield et al. (2005) utilised a large sample size and random assignment to groups, the results and conclusions were restricted due to the limited initial consent rate for participation (66%) and the high drop-out rate by the four-year follow-up (40%).

3.1.2.2 School-based indicated promotion and early intervention programmes for