CRD summary

The authors concluded that the included studies did not provide strong evidence of the effectiveness of school-wide interventions to improve emotional health. These conclusions reflect the evidence presented and are likely to be reliable.

Authors' objectives

To synthesise the available evidence on the effect of interventions to improve the school environment on the emotional health of adolescents.

The impact of the school environment on outcomes was investigated by the authors but does not form the focus of this abstract.

Searching

Six databases including MEDLINE, EMBASE and PsycINFO were searched up to June 2011. An example search strategy for MEDLINE was reported in an appendix. Conference proceedings and trial registers were searched. Reference lists of included studies were checked for potentially eligible studies. All searches were restricted to studies in English.

Study selection

Controlled intervention studies were eligible for inclusion. Studies were included in the review if participants were aged between 11 and 18 years. The intervention target had to be related to structural, pedagogic or relational features of school life. Studies had to include one or more outcome measures of emotional health or self-harm/suicidal behaviour. Studies were excluded if the focus was a very specific group of adolescents, reported only classroom-based interventions, had an exclusive focus on bullying or measured only self-esteem, non-affective mental disorders or behavioural outcomes.

Mean age of participants was not consistently reported and schools from a number of different year/grade systems were included. Most trials included several schools. Various interventions were investigated in the trials. Trials were conducted in Australia, England and the United States and published between 1993 and 2010. A range of outcome measurement tools were used and included standardised tools (such as Children's Depression Inventory, Childrens's Manifest Anxiety scale, Emotional Literacy Assessment Instrument) and tools developed specifically for the individual trial.

Two reviewers selected relevant studies for inclusion.

Assessment of study quality

Sample size calculation, randomisation, allocation concealment, length of follow-up, intention-to-treat analysis, accounting for cluster design, comparability at baseline and loss to follow-up were assessed.

It was not reported how many reviewers assessed study quality.

Data extraction

Various outcome data were extracted; these included odds ratios, mean differences, 95% confidence intervals and p-values. Trial authors were contacted for missing data.

Two reviewers extracted data. Any disagreements were discussed until agreement was reached.

Methods of synthesis

A narrative synthesis was presented due to substantial variation between studies.

Results of the review

Nine articles that reported controlled trials were included: three randomised controlled trials (RCTs) (102 schools, 48 to 5,634 students) and two non-randomised controlled trials (49 schools, approximately 1,680 and 8,630 students).

Three of the five controlled trials were randomised, one provided information on the randomisation process and one reported allocation concealment. Two trials conducted intention-to-treat analyses, two reported power calculations to determine sample size and three were able to account for cluster randomisation in their analyses. Loss to follow-up was not reported consistently but appeared to range from less than 15% to 90%.

Trials provided ambiguous results regarding the effectiveness of the investigated interventions on the emotional health of the participants. Most trials did not find any difference in emotional health outcomes between the invention and control groups.

Results from cohort studies on the impact of school-level factors were provided in the paper.

Authors' conclusions

There was no convincing evidence from most trials that a school-wide approach to improving pupils' emotional health was effective.

CRD commentary

The review question and inclusion criteria were clear. Several relevant sources, including grey literature, were searched. The search was restricted to studies in English so there was a risk that relevant studies reported in other languages were missed. Publication bias was not assessed by the authors; there was an unknown risk that the selection of studies included in this review may have been biased. Use of independent, duplicate processes for study selection and data extraction reduced risks of reviewer error and bias; it was unclear whether the same processes were used for quality assessment.

The authors' decision to summarise studies narratively seemed appropriate. No information was presented on the size of any observed effects. Details of quality assessment were reported and study quality seemed to inform the authors' interpretation of the results. Overall, the trials included in this review provided inconclusive results. The authors acknowledged various limitations associated with the trials, including their limited size and lack of randomisation.

The authors' conclusions reflect the evidence presented and are likely to be reliable.

Implications of the review for practice and research

Practice: The authors did not make any recommendations for practice.

Research: The authors recommend that large-scale studies with natural experimental designs be conducted to further investigate the possible association between students' perceptions of their school environment and their emotional health. Randomised controlled trials in the same area were recommended.

Funding

UK Medical Research Council; UK National Institute of Health Research.

Bibliographic details

Kidger J, Araya R, Donovan J, Gunnell D. The effect of the school environment on the emotional health of adolescents: a systematic review. Pediatrics 2012; 129(5): 925-949. [PubMed: 22473374]

Original Paper URL

http://pediatrics.aappublications.org/content/129/5/925.abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Adolescent; Affective Symptoms /prevention & control /psychology; Child; Cohort Studies; Controlled Clinical Trials as Topic; Humans; Risk Factors; Schools; Social Environment; Social Support

AccessionNumber

12012025699

Database entry date

02/05/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.