Background: There is growing evidence and awareness regarding the magnitude of mental health issues across the globe, starting with half of those before the age of 14 and having lifelong effects on individuals and society. Despite the multidimensional nature of this global challenge, which requires comprehensive approaches, many interventions persist in seeking solutions that only tackle the individual level. This paper aims to provide a systematic review of the evidence for positive effects on children and adolescents’ mental health resulting from interventions conducted in schools and communities where interaction among different agents is an integral component.
Methods: An extensive search in electronic databases (Web of Knowledge, SCOPUS, ERIC, and PsycINFO) was conducted to identify interventions in which interactions between peers, teachers, families or other community members or professionals played a role. Their effects on children and adolescents’ mental health were also reviewed. We carried out a systematic review of papers published from 2007 to 2017. Eleven studies out of 384 met the inclusion criteria. Seven articles reviewed focus on interventions conducted in schools and promote supportive interactions involving students, teachers, families and mental health professionals. Four articles develop interventions that engage community members in dialogic interactions with children and adolescents.
Results: Interventions in schools and communities implement strategies that foster supportive interactions among diverse actors, including teachers, parents, community members, and other professionals. The effects of the mental health interventions reported on children and adolescents problems include a decrease in disruptive behaviours and affective symptoms such as depression and anxiety, together with an increase in social skills, as well as an improvement in personal well-being.
Conclusions: There is evidence of a positive effect on the mental health of children and adolescents, both in decreasing symptoms of mental disorders and promoting emotional well-being. Whereas interactions among different actors seem to be relevant across the interventions, more research is needed to conclude its effect on the outcomes of the studies reviewed.
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Childhood and adolescence are critical periods to promote mental health as more than half of mental health problems start at these stages, and many of these persist throughout adult life (Kessler et al., 2005). This has become a priority as worldwide data shows an increase in the prevalence of mental health issues in childhood and adolescence (de la Barra M, 2009) and the percentage of those afflicted reaching nearly 20% (WHO, 2016). The situation is further exacerbated by the fact that many of these children and adolescents are not receiving the specialized care they require (Mills et al., 2006; Weist & Murray, 2008; Green et al., 2013).
Consequently, important efforts to bring together the best evidence about mental health have been made and raised the challenge of agreeing on fundamental issues in the field, such as the definition of mental health and other related concepts (Mehta et al., 2015). According to WHO, mental health is understood not as a mere absence of illness but rather, in a broader sense, as a state of well-being in which individuals develop their abilities, face the stress of daily life, perform productive and fruitful work, and contribute to the betterment of their community (WHO, 2004). This definition served as the basis for the WHO Mental Health Action Plan, 2013–2020, which incorporates the concepts of mental health promotion, mental illness prevention and treatment, and rehabilitation. Particularly, developmental aspects of children and young people, including, for instance the ability to manage thoughts and emotions, as well as to build social relationships, and the aptitude to learn, are emphasized in the plan as critical facets to be tackled in mental health interventions.
Mental health interventions conducted in schools and communities start from the premise that the problems experienced by adolescents are determined by the interaction of individual, environmental and family factors (Manjula, 2015). Accordingly, schools and communities offer an optimal context to intervene as children and adolescents grow and develop through social interaction. Schools and communities can make the most of their environment to foster child and youth development and promote good mental health (Weist & Murray, 2008). Many of the mental health programs implemented in schools promote the development of social skills, socio-emotional competencies, and learning outcomes while at the same time reducing disruptive behaviour (Dowdy et al., 2010; Moreira et al., 2010; Durlak et al., 2011; Suldo et al., 2014). The school environment and climate can therefore play a critical role in promoting protective factors for mental health, such as social-emotional competencies and skills (Osher et al., 2012).
Hence, social and cognitive development is enacted through social interactions in a particular cultural and social context (Vygotsky, 1978; Bronfenbrenner, 1979). Drawing on the contributions of Vygotsky’s theory of cognitive development, human interaction in the social and cultural context enhances learning and is fundamental for psychological function. These cultural processes in which people learn and develop occur through interactions with others, including symmetrical (peer) as well as the expert–novice (e.g., teacher–student) relations (Rogoff, 1990; Cole, 1996). Specific instruments have been produced to capture effective dialogue across educational contexts (Hennessy et al., 2016).
Most of the research has been devoted to understanding the central role played by the quality of dialogue and interaction between students in small group classrooms or whole class setting teacher-student interaction (see review by Howe and Abedin, 2013). Furthermore, research conducted in community-based schools has also reported the benefit of involving families and community members in learning interactions with elementary students, especially for those belonging to vulnerable populations (Flecha & Soler, 2013; Valls & Kyriakides, 2013). Accordingly, community plays a central role as humans develop through their interactions in the sociocultural activities of their communities (Rogoff, 2003). Similar improvements have been reported among students with disabilities due to engaging in caring and supportive interactions among peers and with other adults when solving academic tasks in interactive groups (García-Carrión et al., 2018). The relevance of effective forms of dialogue and supportive interactions among peers, teachers and other community members have also been reported positive effects on 4th-grade students prosocial behaviour (Villardón-Gallego et al., 2018). These studies evidence the potential of educational interventions that draw on the potential of fostering interactions among different agents and promoting productive dialogues as tools for academic and social improvement.
However, when searching for mental health improvement through dialogic interactions, research is scarce. The pioneering study carried out by Seikkula and Arnkil (2006) showed the psychological and social benefits of the therapy based on open and anticipation dialogues with adults and adolescents that also involved the family along with the professionals. Rather than focusing on the individual, facilitating supportive interactions among peers, professionals and family members might be an asset underpinning mental health interventions with children and adolescents. This study showed the critical role of collective interactions, which were very different from a dialogue between two individuals (Seikkula and Arnkil, 2006). They identified multi-system treatments (MST) characterized by engaging in close interaction professionals with adolescents, family, and other networks. Replication of these US studies in Norway found evidence of effectiveness, particularly, in the adolescents’ social skills (Ogden and Halliday-Boykins, 2004). However, according to Seikkula and Arnkil 2006, p. 181): “what ultimately caused the observed outcome was not revealed. After all, methods do not help or cure anyone as such. Psychological methods -and other interaction-based means- exist as they user activity.”
Whereas, determining the effect of the interaction itself in the outcomes obtained might be problematic, the authors of these paper aim to examine interaction-based mental health interventions, defined as those in which collective interactions, that involve professionals, family and community members with children and adolescents, are an integral component of the intervention. This systematic review focuses on those interventions conducted in schools and communities and its outcomes on children and adolescents’ mental health. According to the WHO definition of mental health provided above, primary studies selected for this review will include positive outcomes in a broader sense, comprising not only the reduction of symptoms of mental disorder but also the promotion of emotional well-being.
The study carries out a systematic review (Gough et al. (2013), a methodology developed by the EPPI Centre of the UCL Institute of Education. We have also taken into account the recommendations by PRISMA (Moher et al., 2009) and checklist by Joanna Briggs Institute (JBI) (Lockwood et al., 2015), in order to offer transparency, validity, replicable, and updateable in this study.
This systematic review has been focused and defined by the question: Do interaction-based mental health interventions in schools and communities have positive effects among children and adolescents? This question has been defined in terms of PICOS: In children and adolescents (Population) are interaction-based interventions (Intervention) effective in decreasing disruptive behaviors and affective symptoms such as depression and anxiety (in children and adolescents with mental health problems), and in increasing social skills, and improving well-being and academic engagement (in children and adolescents in general)? (Outcomes).
For the review, empirical articles published in international scientific journals in the areas of psychology, education, and mental health and focused on interventions among children and youth between 2007 and 2017 were searched and screened. To that effect, the following databases were analyzed: Web of Knowledge, SCOPUS, ERIC, and PsycINFO.
The articles were searched using the following keywords: “school-based,” “community-based,” “dialogue,” “mental health,” “well-being,” “emotional development,” “interventions,” “program,” “interaction,” and “prevention.” The exploration was completed with searches that employed synonyms or derivatives of the keywords. The keywords were also combined to refine the search. The publications containing the search criteria in the title, in the keywords and in the abstract were included.
Inclusion and Exclusion Criteria
In order to identify and select the studies most relevant to our research, inclusion and exclusion criteria were established.
The inclusion criteria were the following:
– Special population group: children and adolescents.
– Target age: 6 to 18 years of age, inclusive.
– Mental health interventions in which collective interactions, including professionals, families, and community members with children and adolescents, are an integral component.
– Studies reporting outcomes of the intervention in decreasing symptoms and/or promoting well-being.
The exclusion criteria were the following:
– Interventions focus on early childhood, youth, or adults.
– Target age is not specified, or the target population is below 5 or above 18 years.
– Mental health interventions focusing on one-to-one interactions (i.e., professional-child/professional-adolescent).
– The intervention is not described or assessed, as in trials, theoretical research or literature reviews.
The first part of the search yielded a total of 384 articles from indexed journals: 183 in published in the WOS database, 12 in Scopus, 33 in ERIC and 156 in PsycINFO. All these articles were entered into the Mendeley software for its screening and review. Basic information such as the title, year, authoring, and abstracts was obtained and introduced in a spreadsheet for a first screening.
From the 384 articles gathered in the initial search, the titles and their authors were subsequently revised in order to eliminate duplicates. This review was carried out by the members of the group independently in order to eliminate duplicate documents, specifically 83 were duplicates and were therefore discarded, resulting in a new total of 301 articles.
Abstracts of the 301 articles were reviewed according to the inclusion and exclusion criteria. As a result, 17 articles initially met the inclusion criteria and were eligible for the review (see Figure 1). The articles were downloaded for an in-depth review.
FIGURE 1. Flow diagram to show the process of study selection.
The three researchers examined the articles independently and extracted the most relevant information that was included in a spreadsheet. The information referred to: (a) study characteristics (author, country, selection criteria, design, data acquisition period), (b) population (target population, age and sample size), (c) settings, and (d) type of study. Once the articles were examined in depth against inclusion and exclusion criteria, discrepancies were discussed to reach a consensus in the final selection of the studies. This first review and discussion of the studies of the 11 articles lead to the elimination of a further six articles that did not adequately fit the inclusion criteria. Thus, a total of 11 articles were finally selected for analysis (Figure 1).
The quality of the selected studies was assessed using a checklist following the methodological guidance for systematic reviews developed by the Joanna Briggs Institute (JBI) (Lockwood et al., 2015). The selected studies were checked against nine questions. The results of the evaluation are presented in the Table 1.
TABLE 1. Quality of studies.
For the analysis of the studies, the three researchers developed an analytical grid to systematize the most relevant information for the purpose of the review: study characteristics, interactions fostered during the intervention, positive effects and information for assessment of the risk of bias. Each researcher analyzed the studies independently aiming at identifying on the one hand, how the interventions promote interactions between different agents, and on the other hand, the effects of the interventions on the target population. Firstly, data was categorized following an inductive method. Secondly, researchers compared their analysis to reach a consensus to report the main findings from the review.
The analysis of 11 mental health interventions targeting children and adolescents reported the benefits for both -students with mental health problems as well as healthy participants- resulting from their participation in the programs analyzed. Nine of the studies show the effects of preventive interventions aim to reduce future problems and to promote mental health among children and adolescents without mental health problems. Only two studies target children who had already contacted the school-based mental health service (Fazel, 2015) and adolescents who presented depressive symptoms (Connell and Dishion, 2008). Overall, the articles reviewed show a series of studies conducted mainly in the US context, seven out of ten, whereas the rest of the studies were carried out in the United Kingdom and Kenya. Seven of the interventions were conducted in schools and four of them were based in the community.
All the studies have shown to promote positive mental health in increasing well-being and preventing other related problems, as well as in reducing affective symptoms among those participants who were already affected. A detailed analysis of the strategies implemented across the mental health programs revealed an emphasis on fostering interactions among the children and adolescents engaging them in dialogues that involved different agents -teachers, families, community members, mental health professionals. An overview of the articles selected is provided in Table 2.
Supportive Interactions in Mental Health Interventions
Interactions among students, teachers, family, and community members and other professionals play an important role in the interventions analyzed. The mental health programs developed in schools and communities include specific strategies that have an emphasis on enacting peer support, partnerships and dialogic spaces for the children and adolescents to engage in supportive interactions with other relevant peers or adults.
Collaborative Interactions Among Children, Teachers and Parents in the School Context
Interactions between teachers and students underpin the strategies of the mental health interventions in different specific ways, which include tutoring, interviews, consultation meetings, peer-assisted learning strategies, interactive games, cooperative non-competitive building games, among others. (Bradshaw et al., 2009; Houlston et al., 2011; Cappella et al., 2012; Ohl et al., 2013; Atkins et al., 2015; Fazel, 2015). Overall, five of the studies implement strategies aimed at developing children’s social skills through interaction and collaboration.
Similarly, interventions focus on “group interactions” as a preventive strategy that seeks to reduce future mental health problems and to promote well-being (McWhirter and McWhirter, 2010). Specifically, two group-oriented prevention programs—Project Family Rejuvenation Education and Empowerment and Group-Oriented Psychological Education Prevention- are characterized by small-group discussions among students and with their mothers; in both settings participants engage in dialogue in a nonthreatening climate while encouraging cultivation of feedback and support between them (McWhirter and McWhirter, 2010).
Moreover, three studies promoted collaborative interactions between parents, teachers, and mental health professionals (Bradshaw et al., 2009; McWhirter and McWhirter, 2010; Atkins et al., 2015). Interactive features of these mental health programs include building positive peer groups and partnerships, solving problems peacefully, and fostering parent-student interactions, among others. This aligns with the need for an integration of the school ecology into program planning and the implementation of effective programs, as observed in the Link to Learning (L2L) service model instituted in classrooms and homes to support children with disruptive behavior disorders living in urban low-income communities (Atkins et al., 2015). In the same vein, collaboration between parents and teachers in classrooms is at the heart of the Family-School Partnership Program (Bradshaw et al., 2009). Discussion-based interactions include parents reading aloud to their children, with a particular emphasis in the promotion of reasoning among the students. Interaction is guided-by open-ended questions after the reading or using other materials, such as videotapes. Parents reacted to and discussed the situations and problem-solved alternative approaches. Discussions were also held on problem situations arising at home.
Fostering Communicative Skills and Home–School Interaction
Communication skills and family communication practice are a central component of READY—a family-based intervention program to prevent HIV infection and mental health problems (Puffer et al., 2016). The interaction and the communication skills training involved families, caregivers, children, and the community, as the intervention was carried out in religious congregations. By improving family communication as a protective factor against mental health disorders, READY draws on a promising approach to strengthen protective family processes that may prevent future negative outcomes for adolescents (Puffer et al., 2016). In conjunction with these activities, and while the program was being implemented, interaction was also fostered, using a voicemail system to cultivate parents’ involvement and to provide consultation on an as-needed basis, and asking parents to fill in and return comment sheets indicating whether they had completed the weekly home activities and whether they had encountered any problems.
For their part, Atkins et al. (2010) carried out an intervention that targeted home-school communication and home routines that support learning, homework support, and daily readings. They promoted interaction between parents and teachers by means of two techniques: Daily Report Cards and Good News Notes. Daily Reports Cards, on the one hand, consist of cards in which teachers and parents join efforts to identify, monitor, and reinforce behaviors that interfere with learning. Teachers and parents agree on a rating system to track behaviors, a reward schedule, and a plan for monitoring intervals that will enhance both direct feedback to students and home-school communication. Good News Notes, on the other hand, are certificates that teachers send to families detailing desirable behaviors exhibited by children, as a means to provide positive weekly feedback to parents. The Notes identify students’ strengths, scaffold behavior improvement by reinforcing small achievements, and balance infraction reports with positive feedback.
Overall, these studies report a multilevel approach, tackling schools, families, communities, and mental health providers and services. The three articles include programs that evidence the crucial role of family and parental engagement in promoting mental health among adolescents (Connell and Dishion, 2008; Puffer et al., 2016) and children (Atkins et al., 2015). According to Connell and Dishion (2008), providing family-centered services in the school environment facilitated family engagement in the program.
Engaging in Dialogue With Community Members
Engaging in dialogue with the very community members who might be at risk of suffering mental health problems is essential for the success of the intervention. Some strategies for their involvement include the creation of a local Community Advisory Committee (Puffer et al., 2016) or a Community Advisory Board (Kia-Keating et al., 2017). The latter engage participants in reciprocal dialogues on solutions for issues ranging from violence exposure and health disparities to the difficulties encountered by youth people seeking to thrive, as exemplified by the HEROES Project (Kia-Keating et al., 2017).
There have been other community-based organizations studied in California, aimed at promoting “cultures of health” by engaging people in building social networks, by fostering solidarity and collective efficacy, or by promoting a shared commitment to the collective well-being (Puffer et al., 2016). Overall, these programs promote dialogic spaces in which the voices of the minorities, who have often been excluded, are instead given prominence and listened to, in order to look for solutions that will address the inequalities affecting their communities.
Ryan is a 12 year old diagnosed with Oppositional Defiant Disorder (ODD). As a small child, Ryan was first diagnosed with Attention Deficit, Hyperactivity Disorder. He had just started preschool and was unable to remain in one place for more than a minute or two. His parents had already had a very difficult time in disciplining him, because he would become very upset and throw temper tantrums when he could not do as he wished. He just seemed to be an unhappy, irritable child. This behavior continued in school. As time progressed, Ryan was diagnosed with Oppositional Defiant Disorder, because he continued to refuse to listen to adults and comply with the rules.
By the age of 12, he has begun to bully and annoy others. His parents have decided that the approaches they have used in the past are not working, and they are more afraid his behavior will only get worse.
Provide explanations for these questions and statements:
Describe the behaviors apparent for each disorder in this scenario (Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder).
If this behavior becomes worse and Ryan starts to violate the rights of others, what medical diagnosis will be given and why?
Discuss at least two types of medication appropriate to treat Ryan and support your choices with rationale and credible resources
Describe why therapy for the parent is important in this scenario including at least two supporting rationales.