Assessing the Evidence Base for School-Based Promotion and Prevention Interventions: Introduction to the Series
Abstract
Schools are an important component in the mental health system of care for youths. Teachers and other school staff have unique opportunities to promote emotional wellness and prevent mental health conditions. Although numerous programs are available, identifying evidence-based and effective options is a significant challenge. This introduction lays out the rationale and methodology of the Assessing the Evidence Base (AEB) Series, a collection of systematic reviews of school-based mental health promotion and prevention approaches recommended by the National Academies of Sciences, Engineering, and Medicine for students in kindergarten through grade 12. Authors of the current AEB Series used the rating criteria derived from the 2014 AEB Series, which provided systematic reviews of a wide spectrum of interventions for mental and substance use disorders. Like its predecessor, the current series upholds a high standard of scientific rigor while ensuring that the information is easily accessible to various stakeholders in education, behavioral health, and communities. It describes the universal features included in each systematic review, such as a rating of the level of evidence for interventions, intervention program components, identification of interventions that have yielded positive outcomes for students from underserved populations, and a review of cost data. The AEB systematic reviews will serve as an important tool for decision makers involved in managing limited resources for various programs in school-based mental health services by synthesizing large bodies of research for use by leaders in education and behavioral health.
HIGHLIGHTS
Schools are an important component of the pediatric mental health services continuum, and decision makers need rigorous information regarding the effectiveness of interventions for mental health promotion and mental disorder prevention in school settings.
The Assessing the Evidence Base (AEB) Series provides systematic reviews of school-based mental health interventions for students in kindergarten through grade 12 and uses established criteria to rate the level of evidence of interventions’ effectiveness.
The authors describe the rationale and methodology of the AEB Series, including analyses of the level of evidence for general and underserved populations, program components across interventions, and available cost data.
Editor’s Note: The Assessing the Evidence Base Series provides systematic reviews of the literature from 2008 to 2022 and rates the level of evidence for school-based mental health promotion and prevention interventions by using established standardized criteria. Target audiences include state authorities; administrators; providers; researchers; students; family members; and leaders in behavioral health, education, and the community, as well as others interested in empirical evidence establishing the effectiveness of school-based interventions.
The prevalence of mental health conditions among children and adolescents is increasing, and concerns are growing regarding difficulties for youths and parents in accessing early intervention of mental health services (1–3). Before the COVID-19 pandemic, some studies showed that one in five children and adolescents (ages 3–17 years) has a mental, emotional, developmental, or behavioral health disorder (4). During the pandemic—because of significant losses of primary caregivers, increased social isolation, and changes in social milieus due to school closures—youths had higher rates of psychological distress, suicidal ideation, and suicide attempts (5, 6). These negative outcomes were more pronounced among youths who identify as LGBTQIA+ (i.e., lesbian, gay, bisexual, transgender, queer or questioning, intersex, or asexual), youths of color, and those in low-income families (2, 3, 7).
Decision makers (e.g., federal and state authorities and administrators and leaders in behavioral health, education, and the community) have recognized the importance of addressing mental health and wellness early and the value of doing so in schools. In 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a national state of emergency of children’s mental health (8). “Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory” highlighted the urgent need to address the nation’s youth mental health crisis (2, 6). In February 2023, the White House Report on Mental Health Research Priorities called for the expansion of school-based mental health interventions to address the mental health crisis among youths (9). It is broadly acknowledged that there is an immediate need for action to ensure the emotional well-being of young people.
Programs that include interventions for mental health promotion and prevention of mental disorders play a central role in a public health approach to addressing students’ emotional and behavioral needs. Mental health promotion interventions aim to enhance students’ ability to achieve developmentally appropriate tasks (competence) and reinforce a positive sense of self-esteem, mastery, well-being, social inclusion, and the ability to cope with adversity (10, 11). Mental health prevention interventions aim to reduce the risk for the development of mental disorders and are offered before the onset of the disorder they are intended to prevent. Prevention interventions may target the general student population (universal), a subgroup of students who are at higher risk for developing mental disorders (selective), or high-risk students who may show some signs or symptoms but do not meet diagnostic criteria for specific disorders (indicated) (10).
The Case for School Mental Health
Schools are a part of the mental health system of care (12) and a common venue for providing mental health services to youths (13). Children and adolescents, referred to collectively as youths, spend a substantial portion of their day in school. This fact makes schools an ideal setting for mental health promotion and prevention programs to positively influence the behaviors and thoughts of youths and to intervene before mental health conditions develop (12).
Promotion and prevention interventions can be delivered to entire classrooms simultaneously or districtwide and have the potential to reduce the risk for negative outcomes and the need for higher levels of mental health care in community settings (12, 14). Early detection of mental health issues, along with the provision of interventions in schools, can increase early access to effective, evidence-based mental health services and address inequities or disparities for individuals from diverse racial and ethnic backgrounds (15). This latter focus is of particular significance because approximately 15% of public schools in the United States are classified as multiethnic (16). Offering school-based services addresses common barriers such as transportation, financial constraints, and stigma.
Frameworks such as PBIS (positive behavioral interventions and supports) and MTSS (multitiered systems of support) provide convincing evidence for the need and value of mental health promotion and prevention interventions in school settings, yet decision makers face significant challenges in discerning which interventions have evidence of effectiveness in improving mental health outcomes (17).
In the past 3 years, significant legislation that expands school-based mental health programs has been passed in the United States. The American Rescue Plan Act (ARPA) of 2021 allocated $122 billion in funds available to states, Washington, D.C., and Puerto Rico for schools to help students catch up academically and access mental health services (18). The Bipartisan Safer Communities Act (BSCA), signed into law in June 2022, set aside nearly $1 billion for school programs, including the expansion of school-based mental health services (19). The BSCA includes funding for Project Advancing Wellness and Resilience in Education, which supports the development of sustainable infrastructure for school-based interventions, including mental health promotion and prevention programs. In July 2022, the Biden-Harris Administration announced a series of actions that leverage ARPA and BSCA funds to support students’ academic and mental health recovery and strengthen school-based mental health services (20). Recognizing the importance of schools within the continuum of mental health care, in 2023, the Centers for Medicare and Medicaid Services published an administrative billing guide (21) outlining recommendations and policies to enable states to authorize schools to bill Medicaid for school-based services it covers, extending this benefit to all Medicaid-enrolled students and not limited to students in individualized education programs.
Mental Health Promotion and Prevention Interventions Within Schools
The National Academies of Sciences, Engineering, and Medicine; the Centers for Disease Control and Prevention; and others consider promotion and prevention interventions to be critically important components of the intervention spectrum, particularly in terms of fostering academic, mental, emotional, and behavioral health among youths (10, 22–25). Moreover, evidence suggests that school-based mental health promotion and prevention approaches are key parts of the services continuum that have been shown to be effective in increasing positive behaviors and outcomes, academic success, competence, and well-being and to decrease negative outcomes, such as mental health conditions, conduct problems, and dropout from school (10, 22, 26). Offering interventions in schools broadens the reach of mental health services and increases access to care among students from underserved populations (27, 28).
Hundreds of interventions focus on mental health promotion and prevention in schools (29–31), with substantial research support for some of these interventions. Although research into many interventions exists, more is needed to identify which interventions have a high level of evidence of effectiveness for students in general populations and for students from underserved populations, program components that work across the interventions, and which interventions are most cost-effective.
The Assessing the Evidence Base Series
The Assessing the Evidence Base (AEB) Series systematically reviews and synthesizes information on school-based mental health promotion and prevention interventions. The series addresses decision makers’ needs for evidence-based approaches and covers topics recommended by the National Academies of Sciences, Engineering, and Medicine (22), including bullying, disruptive and distracting behaviors, mindfulness, social-emotional learning, trauma, and suicide prevention. For each topic, a systematic review was conducted to identify interventions with the highest level of evidence, the program components that span interventions, interventions tested with underserved populations, and information on the cost-benefit or cost-effectiveness, when available.
The AEB Series builds on the success of a previous series of 14 articles published in Psychiatric Services in 2014. As shown in Table 1, that series featured mental health and substance use disorder treatments and services of interest to decision makers at the federal, state, and community levels. As of this writing, articles within the previous series (32–45) have been cited >2,700 times since their publication. We briefly outline the approach and scope of the reviews in the current AEB Series.
| Study | Title | N of times citeda |
|---|---|---|
| Dougherty et al. (32) | Assessing the Evidence Base for Behavioral Health Services: Introduction to the Series | 22 |
| Chinman et al. (33) | Peer Support Services for Individuals With Serious Mental illnesses: Assessing the Evidence | 582 |
| De Arrelano et al. (34) | Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents: Assessing the Evidence | 326 |
| Fullerton et al. (35) | Medication-Assisted Treatment With Methadone: Assessing the Evidence | 305 |
| Johnson et al. (36) | Behavioral Management for Children and Adolescents: Assessing the Evidence | 31 |
| Lyman et al. (37) | Consumer and Family Psychoeducation: Assessing the Evidence | 72 |
| Lyman et al. (38) | Skill Building: Assessing the Evidence | 43 |
| Marshall et al. (39) | Supported Employment: Assessing the Evidence | 286 |
| McCarty et al. (40) | Substance Abuse Intensive Outpatient Programs: Assessing the Evidence | 94 |
| Reif et al. (41) | Peer Recovery Support for Individuals With Substance Use Disorders: Assessing the Evidence | 292 |
| Reif et al. (42) | Recovery Housing: Assessing the Evidence | 46 |
| Reif et al. (43) | Residential Treatment for Individuals With Substance Use Disorders: Assessing the Evidence | 112 |
| Rog et al. (44) | Permanent Supportive Housing: Assessing the Evidence | 349 |
| Thomas et al. (45) | Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence | 236 |
| Total | NA | 2,796 |
TABLE 1. Review articles of the 2014 Assessing the Evidence Base Series
Methods
Each systematic review in the AEB Series adhered to a consistent methodology, detailed in this section and covering the following: defining the topics, systematically reviewing the relevant literature, rating the level of evidence, identifying program components that appear across interventions, assessing evidence concerning interventions’ effectiveness for underserved populations, and reviewing available information to conduct an economic analysis of the interventions. The systematic review articles feature text boxes that provide decision makers with a summary of the results related to these six components.
Defining the AEB Topics
Before commencing each systematic review, the review authors conducted a preliminary examination of gray literature to delineate the subject matter and guide the formulation of topic-specific inclusion and exclusion criteria. The definition of each topic also incorporated specific objectives for the interventions, which were subsequently required to be addressed within the studies selected for review. The interventions featured in the AEB Series are primarily school based, with the potential inclusion of after-school or homework components. Included studies encompassed those with students in kindergarten through to grade 12, and some involved teachers, parents, and other key figures within the student support system. Although pre-K programs are present in many states, the decision to include students only as of kindergarten was intended to focus the reviews on programs that are available to all students. A large portion of children in the United States do not attend nursery school, preschool, and pre-K programs because of parental choice or financial constraints. In contrast, starting in kindergarten, nearly all youths are enrolled in the school system or have the option of going to a public school.
The AEB Series includes interventions that aim to reduce the development of mental health conditions among students and the associated clinical and family burdens. Across all topics, the inclusion criteria mandate that studies must encompass mental health outcome measures demonstrating positive outcomes related to the topic. The rationale for this selection criterion was that mental health conditions take a significant emotional, physical, and financial toll on youths, parents, schools, communities, and society (2). From a public health policy perspective, interventions that can proactively prevent mental disorders and enhance student well-being represent a valuable and justified public investment (46).
Systematic Literature Review
To identify a comprehensive body of evidence in each topic area, the review authors conducted a survey of major databases, including PubMed, PsycInfo, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Social Science Database, Sociology Database, ERIC, ProQuest’s Education Database, and EBSCO’s Education Source. Authors also searched the gray literature, including government websites and evidence-based registries.
Across the AEB Series, authors included individual U.S. and international studies published in English from 2008 through 2022. The decision to include international studies was based on the belief that much may be learned from research conducted outside of the United States, especially related to prevention and promotion programs. Although international studies introduce additional contextual variables, excluding them would have limited an understanding of the evidence for specific interventions. The systematic reviews specified evidence by country to permit cross-cultural learning. Bibliographies of meta-analyses and research reviews were also examined to ensure that all relevant studies are covered.
Because the AEB Series is focused on mental health promotion and prevention interventions, the studies were selected to include mental health outcomes. However, some studies also included data related to academic performance or other outcomes. Interventions were excluded if the study focused on mental health treatment (as opposed to promotion or prevention) or targeted students with specific clinical diagnoses, although students with these conditions may have been (and likely were) included in classrooms where the interventions were implemented.
To identify eligible studies, the review authors worked in teams of three to five. At least two independent reviewers examined each abstract identified during the literature search. If the reviewers did not initially agree on whether to include a study in the analyses, they discussed the reasons for including or excluding the study to reach a consensus opinion or they engaged a third reviewer to review the abstract or full article. The primary authors of each review examined the full articles to decide which studies to include in the review.
Levels of Evidence for the Effectiveness of Interventions
Each systematic review rated the level of evidence for interventions that met the inclusion criteria (32). Ratings were based on the collective evidence for all published studies of that intervention. In addition to identifying the number of studies, the review authors used the ratings of the level of evidence to consider the overall quality of the research by examining the adequacy of the study designs for testing the interventions. Individual studies that had sample sizes of ≤20 participants in any one condition were excluded (47), and methodological weaknesses were identified and factored into the ratings.
Studies included in the systematic reviews comprised randomized controlled trials (RCTs), quasi-experimental designs, and comparative studies conducted in schools. Review authors examined results across these types of research when synthesizing the evidence base for selected interventions. Some studies had less rigorous methods because of constraints and limitations of the settings in which the research was conducted (e.g., where randomization was not possible); however, studies with emerging evidence without comparison groups were not included.
Table 2 summarizes the established criteria applied in the AEB Series reviews to rate the level of evidence. Ratings (i.e., high, moderate, and low) were based on predefined benchmarks that considered the number and quality of the reviewed studies. High-evidence ratings indicated confidence in the reported outcomes and were based on three or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with adequate designs. Moderate-evidence ratings were based on two RCTs with adequate designs, one RCT plus one quasi-experimental study with adequate design, three or more quasi-experimental studies with adequate design, or four or more quasi-experimental studies with methodological weaknesses (i.e., studies that did not account for baseline differences between the experimental and comparison groups studied). Low-evidence ratings were based on one or no RCTs and two or fewer adequately designed quasi-experimental studies.
| Rating and definition | Research design | N of studies needed |
|---|---|---|
| High evidence: the number and quality of studies for this intervention indicate confidence in the reported outcomes; although additional research may be conducted to further examine key results, it is anticipated that these findings will not significantly change the evidence. | Includes chiefly randomized controlled trials (RCTs), which are considered to provide a high level of evidence because they use random assignment to experimental and control groups | ≥3 RCTs with adequate designs or 2 RCTs plus 2 quasi-experimental studies with adequate designsa |
| Moderate evidence: adequate research is available to judge this intervention, although future research could influence evidence based on the reported results. | Includes RCTs and quasi-experimental designs, which are considered to establish a moderate level of evidence because they have nonrandomized comparison groups, which may or may not be properly matched or have statistical controls to test for differences between groups; some quasi-experimental designs have a single-sample, time-series design, which allows for comparisons. | 2 RCTs with adequate designs, or 1 RCT plus 1 quasi-experimental study with adequate designs, or ≥3 quasi-experimental studies with adequate designs, or ≥4 quasi-experimental studies with methodological weaknesses (i.e., studies that do not account for baseline differences among groups) |
| Low evidence: the research for this intervention is not adequate to draw evidence-based conclusions about an intervention’s effectiveness; research of adequate quality on this intervention is needed, and results from such studies are likely to change conclusions about the intervention’s effectiveness. | Includes studies that lack a comparison group or time-series design (e.g., single-group, pre-post designs), which are considered to provide a low level of evidence because such designs do not allow for examination of effects for the same group over time or for comparisons with groups that do not receive the experimental treatment. | 1 or no RCTs or ≤2 quasi-experimental studies with adequate design |
TABLE 2. Criteria for rating levels of evidence in the current Assessing the Evidence Base Series
Other methodological and research design factors that could affect evidence ratings, such as how the populations and interventions were defined, use of statistical methods to account for baseline differences between the experimental and comparison groups, identification of moderating or confounding variables with appropriate statistical controls, examination of attrition and follow-up, and indications of potential research bias, were also considered. If ratings were dissimilar, a consensus opinion was reached through discussion.
Intervention Components
For each intervention, program components were examined qualitatively to understand similarities across interventions. Assessing the intervention components was crucial because of the diversity of the various programs, all of which share the common objectives of promoting mental health or preventing mental health conditions (29, 31). Identifying which program components were included in interventions and collectively have a high level of evidence provides decision makers with valuable insights for selecting interventions that have components with known effectiveness.
Implementation With Underserved Populations
To study the level of evidence of interventions for underserved populations, the authors of the systematic reviews assessed whether the studies examined differences for students from diverse backgrounds. Underserved populations have been defined through a White House Executive Order as populations that share a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life (48). Using this definition, the reviews examined studies conducted in the United States in which ≥70% of the sample comprised students from underserved populations, such as students from diverse racial-ethnic backgrounds or students identifying as LGBTQIA+. Diverse race and ethnic backgrounds included students identifying as African American/Black, Hispanic/Latino, Asian, Pacific Islander, American Indian, Alaska Native, Native Hawaiian, or multiracial. Students who identified as White/Caucasian or other or unknown were not included in this total. Authors also documented whether studies identified instances of lower socioeconomic status, including schools described as Title I and the percentage of students receiving free and reduced-cost lunches.
Cost Analysis
Across the AEB Series, review authors used a keyword search to identify studies that included the term “cost” and systematically reviewed and assessed the cost evidence included in the articles to determine whether the studies provided sufficient information for a cost-effectiveness or cost-benefit analysis. Studies included in a cost analysis met the following criteria: the research design was controlled (i.e., an RCT or a quasi-experimental design), the study found significant impacts on the primary outcome, and the study measured costs of the intervention as tested. For purposes of comparison, costs were converted to 2023 U.S. dollars when cost data were available.
Implications of the AEB Series
The findings from the systematic reviews in the AEB Series have implications for decision makers at the federal, state, and local levels, and as such, have been written to be responsive to their needs. The systematic reviews rate the level of evidence for specific interventions, identify common program components, capture known positive outcomes, and highlight interventions tested with students from underserved populations. The findings of these reviews may help decision makers in determining which interventions to select to best meet the needs of their schools and students. Information related to the cost-effectiveness of the interventions can help decision makers make choices regarding which mental health promotion and prevention programs to implement in schools. The systematic reviews also consider areas that can help strengthen the evidence base and facilitate recommendations for future research.
Conclusions
The AEB systematic review series will serve as an important tool for decision makers involved in managing limited resources for promotion and prevention programs in school-based mental health services by synthesizing large bodies of research so that leaders in education and behavioral health can use the research findings. As more schools begin to implement these programs and the evidence base grows, these interventions will likely have a considerable impact on youths’ mental health and well-being.
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