Paulus 2016

Journal of Child Psychology and Psychiatry **:* (2016), pp **–** doi:10.1111/jcpp.
12584
Practitioner Review: School-based interventions in

child mental health
Frank W. Paulus,1 Susanne Ohmann,2 and Christian Popow2
1
Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany; 2Department of
Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
Background: School-based interventions (SBIs) are well-established and effective treatments for improving child
mental health. Specific school-based topics include prevention (Tier I–III) and interventions (e.g. cognitive–
behavioural programmes and daily report cards). Methods: We performed a systematic literature search in five
commonly used online databases (ERIC, MEDLINE, PsycARTICLES, PsycINFO and PSYNDEX) for English-language
articles published between 1993 and 2015. Additional sources included reference lists of relevant articles and book
chapters. Results: We identified a number of successful behavioural or cognitive–behavioural programmes yielding
moderate to strong effects for a range of emotional and behavioural problems. The implementation of these
programmes and the collaboration of the involved settings (school and home) and persons are important factors for
their effectiveness under real-life conditions. Conclusions: Effective SBIs are valuable tools for students with mental
health problems if evidence-based cognitive–behavioural interventions are applied and rules of translational
algorithms and implementation science are respected. Keywords: Schoolchildren; school; intervention; prevention;
behaviour therapy.
2000). This definition also includes non-school-based

Introduction
interventions (SBIs), for instance, parental training.
Children spend a significant percentage of their
There are a number of effective, research-based
time at school, a complex system that involves
SBI available (Bray & Kehle, 2011). Such SBIs on the
multiple social interactions with peers and adults.
basis of well-established (cognitive–) behavioural
Within this setting, cognitive, emotional and social
interventions are effective: preventive and therapeu-
skills are required and modified. In addition, social
tic measures may reduce dysfunctional cognitions
and ethical values like honesty, mutual consider-
and behaviour as well as functional impairment
ateness and fairness are imparted. However, social-
(Barry, Clarke, Jenkins, & Patel, 2013; Greenberg,
isation within the complex school environment also
Domitrovich, & Bumbarger, 2001; Hahn, Fuqua-
bears the risk of developing mental problems and
Whitley, & Wethington, 2007; Hoagwood et al.,
disorders that in turn complicate the socialisation
2007; Neil & Christensen, 2009; Wilson, Lipsey, &
process. Academic functioning and mental health
Derzon, 2003). Table 1 lists characteristics of SBI
are strongly interrelated: academic functioning can
and differences to standard office psychotherapy.
be impaired by mental health problems (MHP) that
It may be difficult to transfer interventions from
in turn can be impaired by poor academic func-
research projects to the real school environment
tioning.
because strictly following a manualised programme
Up to a quarter of school-aged children display
may not meet the actual needs of students or
significant MHP (Costello, Mustillo, Erkanli, Keeler, &
teachers. Most schools in the United States (nearly
Angold, 2003), but 70–80% of students receive no
80%) offer some kind of – usually not well grounded –
mental healthcare at all (Egger & Angold, 2006;
behavioural interventions (Gottfredson & Gottfred-
Farmer, Burns, Phillips, Angold, & Costello, 2003;
son, 2001), mostly part-time student counselling. To
Farrell & Barrett, 2007). For these children, the edu-
a lesser extent, schools employ school psychologists,
cational sector may provide meaningful support (Burns
nurses or social workers, and only a few offer mental
et al., 1995). It therefore seems advisable to implement
health and social services via school-based health
school-based services for improving the mental health
centres. Commonly, arrangements with profession-
of students because schools can directly identify MHP
als located outside the school area are provided
and intervene on the spot (Kazdin & Johnson, 1994).
(Brener, Weist, Adelman, Taylor, & Vernon-Smiley,
Such services are defined as ‘any programme, inter-
2007).
vention or strategy applied in a school setting that was
School-based interventions and their efficacy are not
specifically designed to influence students’ emotional,
‘popular’ and only partially known to healthcare pro-
behavioural or social functioning’ (Rones & Hoagwood,
fessionals (psychiatrists, psychologists, psychothera-
pists and nurses). We, therefore, wanted to provide an
overview on SBI for healthcare professionals based on
Conflict of interest statement: No conflicts declared. a thorough literature search. The aims of this
© 2016 Association for Child and Adolescent Mental Health.

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
2 Frank W. Paulus, Susanne Ohmann, and Christian Popow
Table 1 School- versus office-based interventions
School based Office based
Setting Complex, natural Initiated

Temporal Within the regular school routine (restricted), in the leisure time
constraints
Areas of interventions Primary: school context Primary: office
and assessing effects Secondary: transfer to home and leisure context Secondary: transfer to home and leisure
context and school
Persons involved Classmates Psychotherapist/psychologist
Classroom teachers Parents or caretakers
Special education teachers Siblings
School (or assistant) psychologists Peers
School social workers Others
School nurses
Coordinators
Others
Interventions Health promotion, prevention and/or treatment Primary: treatment
Psycho-education Psychotherapy, psycho-education provided
Psychotherapy provided by trained individuals by psychotherapist
like (para-) professionals, consulting professionals, Individual, group or family based
trained or expert teachers, school psychologists
School, class, group or individual based
overview are (a) to improve knowledge about SBI, (b)

SBI for prevention and treatment
to specify some effective preventive and therapeutic
Prevention
programmes and (c) to discuss prerequisites and
significant aspects of the implementation process. Preventive measures are applied to individuals with-
Our review mainly addresses healthcare experts out present MHP. The US Public Health Service
because they usually are involved in the healthcare highlights the importance of fostering social and
of students with mental and behavioural problems emotional health of children by applying preventive
but have only little experience with SBI. We address measures (US Public Health Service, 2000). School
structures in rather wealthy countries where psychi- provides an ideal environment for prevention
atric and psychotherapeutic services are available to because the majority of students including those
a certain extent. For mental health interventions in without access to mental health services can easily be
low- and middle-income countries, we refer to an attended. The relevance of school-based prevention
excellent recent review (Fazel, Vikram, Thomas, & (SBP) has been confirmed by an increasing number of
Tol, 2014). studies in the past two decades (e.g. Greenberg,
2004; Greenberg et al., 2001; Rones & Hoagwood,
2000; Weisz, Sandler, Durlak, & Anton, 2005).
Methods Mrazek and Haggerty (1994) defined three levels of
This review is based on a systematic literature search of SBI in preventive interventions: universal, selected and indi-
peer-reviewed journals. We systematically searched five com-
monly used online databases (ERIC, MEDLINE, PsycARTI-
cated prevention (Tier I–III), depending on an individ-
CLES, PsycINFO and PSYNDEX) for articles and books ual’s risk of acquiring a MHP (O’Connell, Boat, &
published in the last two decades, using the following items: Warner, 2009). ‘Mental health promotion’ describes
‘school’ (i.e. school-based, preschool, elementary school, mid- measures for improving psychological well-being and
dle school and high school) and ‘child mental health’ (i.e. resilience, overlaps with Tier I prevention and aims at
mental health, disorder, anxiety, depression, externalising
behaviour, internalising disorder, attention-deficit/hyperactiv-
preventing diagnosable disorders. Weisz et al. (2005,
ity disorder (ADHD), oppositional defiant disorder, conduct p. 633) linked prevention and treatment research.
disorder, substance abuse, autism spectrum disorder and They included ‘health promotion/positive develop-
retrieved 6.867 articles). The search, ‘school’ and ‘disorder’, ment’, Tier I–III interventions, three types of therapy,
resulted in 268.632 articles, and ‘school’ and ‘mental health’ time-limited, enhanced, and continuing care, and
resulted in 128.690 articles. We only considered English-
language articles published between 1993 and 2015 in Euro-
various intervention settings, e.g. school and primary
pean, North American and Australian journals. Due to the care clinic in a complex multilevel model, ‘an integra-
large number of retrieved articles, we primarily focused on tive model for linking prevention and treatment
reviews and overviews (Table 2 and text), subjectively selecting research’. Table 3 lists effective school-based pro-
and concentrating on practitioner-relevant effective programmes.
grammes for MHP (Table 3 and text).
Our review is organised in the following three sections:
Prevention and Treatment, Implementation of SBI, and Prac- SBP overview. Effective programmes were sum-
tical Implications and Future Considerations. marised by the World Health Organization (WHO)

School-based interventions 3
Table 2 Meta-analyses and reviews on SBI. The Table is organised in three parts: (a) General topics and specific targets or disorders,
(b) Internalising, (c) Externalising disorders
n Studies
Study Targeted MHP (programmes) Period Results
(a) General topics and specific targets or disorders

Bellini et al. (2007) Autism spectrum disorder 55 1980–2005 Overall minimal effective
(Tier III) (ASD): s-b social skills interventions
interventions Questionable intervention
(MA) effects (n = 52, PND M = 70%,
range 17–100)
Moderate maintenance effects
(n = 25, PND M = 80%,
range = 17–100%)
Low generalisation effects
(n = 15, PND M = 53%,
range = 17–100%)
Cox (2005) Analysis of home-school 18 1980–2002 Collaboration interventions are
(Tier III) collaboration effective in helping achieve
interventions desired school outcomes
(R) Strongest ES in interventions
with collaboration (two-way
exchange of information) of
school personnel and parents
together with communication
(DRC and school-to-home
notes)
Farahmand, A spectrum of disorders: 19 programmes 1985–2009 Overall extremely small ES
Grant, Polo, s-b mental health and Evident effectiveness for
Duffy, and behavioural programmes internalising problems and
DuBois (2011) for low-income, urban universal interventions
(Tier I–III) youth Negative effects for
(MA) externalising problems and
selective interventions
Forman & Barakat Factors influencing the 21 1990–2009 Five factors: school
(2011) success of organisational structure;
(Tier I–III) implementation (of new programme characteristics;
CBT programmes and fit in school goals, policies
practices) in school and programs; training/
settings technical assistance;
(R) administrator support
Franklin, Kim, Extent of teacher 49 1999–2010 Overall small ES, ranged from
Ryan, Kelly, involvement in School 0 to 1.89
and Montgomery Mental Health Different personnel (teacher,
(2012) Intervention (SMHI) SMHI professional) achieved
(Tier I) (R) similar outcomes
In 40.8% of interventions:
teachers actively involved, in
18.4% teachers as exclusive
providers
Many SMHIs are universal and
take place in the classroom
Fryda and Hulme Prevention of child sexual 26 1984–2012 Positive effects on knowledge,
(2015) abuse self-confidence and
(Tier I) (R) protection skills, no negative
effects
Hoagwood et al. S-b interventions to 24 examine 1990–2006 Significant effects on both
(2007) promote academic and both outcomes mental health and academic
(primarily Tier I–II) mental health functioning performance in 15 studies
(R) (62.5%)
Positive effects on mental
health outcomes solely in
eight studies (33.3%)
(continued)

Table 2 (continued)
n Studies
Mendez et al. S-b mental health 100 (39 1995–2010 Potential to improve outcomes
(2013) interventions involving interventions) in multiple domains
(Tier I–II) parents in school settings More multitier programmes
(R) are needed
Involve parents most
commonly by group-based
parent training
Reese, Prout, S-b psychotherapy and 65 1998–2008 ES = 0.44
Zirkelback, counselling dissertations: Largest ES in skills training
and Anderson effectiveness and file- (ES = 0.55) and interventions
(2010) drawer (publication bias) with elementary school
problem students (ES = 0.65)
(MA) A bias exists with unclear
extent, but appears smaller
compared to the general child
psychotherapy literature
Robinson et al. Suicide: s-b interventions 43 (15 Tier I, 1988–2011 Overall limited evidence (esp.
(2013) regarding suicide-related 23 Tier II, Tier I, III, postvention),
(Tier I–III) behaviours (prevention, 3 Tier III, 2 hampered by a lack of RCTs
early intervention and postvention) Reasonable evidence for
postvention) gatekeeper training
(increasing knowledge,
knowing warning signs) and
screening programmes (early
identification) (both Tier II)
Rolfsnes and Idsoe Posttraumatic stress 19 Prior to May 2010 Medium-large overall ES (0.68)
(2011) disorder: s-b intervention 11 of 16 studies used CBT
(Tier III) targeted at reducing techniques largely effective
PTSD symptoms School professionals can be
(MA) successfully utilised in
providing interventions
Rones and Hoagwood Spectrum of disorders 47 1985–1999 36% effective, 36% mixed, 28%
(2000) (depression, conduct ineffective. Lack of studies
problems, substance use, directly targeting particular
stress): s-b mental health clinical syndromes
services Important features: consistent
(R) programme implementation,
use of multiple modalities,
integration in classroom
curriculum, developmental
appropriate programmes,
involvement of parents,
teachers, peers
Suhrheinrich, ASD Examples of successful
Hall, Reed, (R) programmes, mainly based
Stahmer, and on Applied Behavioral
Schreibman (2014) Analysis
Ttofi and Bullying: s-b programmes 89 (53 1983–2009 Overall effective: bullying
Farrington programmes) decreased by 20–23% and
(2011) victimisation decreased by 17
–20%
More effective: more intensive
programmes, including
parent training, firm
disciplinary methods,
improved playground
supervision, whole-school
antibullying policy
Work with peers increases
victimisation
(continued)

Table 2 (continued)
n Studies
Vreeman (2007) Bullying: s-b-interventions 26 1994–2004 Decreased bullying in 7 of 10

(10 studies curriculum, multidisciplinary, whole-
10 multidisciplinary, 4 school interventions
social skills groups, 1 (combination of school-wide
mentoring, 1 social rules and sanctions, teacher
worker support) training, classroom
(R) curriculum, conflict
resolution training and
individual counselling)
No clear reduction in 3 of 4
social skill trainings and 6–9
of 10 studies with curricular
changes
Wells, Barlow, Mental health promotion 17 1982–1999 >50% of the studies showed
and Stewart- and illness prevention: positive effects for more than
Brown (2003) s-b universal approach 30% of outcome measures
(Tier I) (R) More successful: Provided
continuously over 1 year or
longer;
Whole-school approaches
(including students, staff,
families, community) to
change culture and
environment of the school
(b) Internalising disorders
Calear and Christensen Depression: prevention 42 (28) 1998–2008 Tier I: 39% of 23 studies show
(2010) and intervention reduction in depressive
(Tier I–III) programmes symptoms (ES d = 0.30–1.40)
(R) Tier II: 50% of 6 studies show
reduction (ES d = 0.48–1.01)
Tier III: 60% of 10 studies
shows reduction (ES d = 0.25
–1.35) (most efficacious)
Mental health professionals
have better effects than
teacher programme leaders
Durlak et al. Social and emotional 213 1955–2007 Significant overall ES for
(2011) learning (SEL): s-b, social-emotional skill
(Tier I) universal programs performance (0.57), positive
(MA) social behaviour (0.24),
academic performance (0.27),
conduct problems (0.22),
emotional distress (0.24),
attitudes (0.23)
Teacher/school staff effectively
conduct SEL; no additional
benefit of multicomponent
programs
Moderators: use of SAFE
practices, presence of
implementation problems
Gonzalez-Suarez, Childhood obesity: s-b 19 1995–2007 Schools are favourable settings
Worley, prevention and for short-term obesity
Grimmer-Somers, management prevention (decreasing odds
and Dones (2009) (MA) of participants overweight
and obese)
Intervention programmes were
not effective in reducing BMI
(ES = 0.62)
Longer running programmes
(>1 year) were more effective
(continued)

Table 2 (continued)
n Studies
Kavanagh et al. (2009) Symptoms of depression, 17 Since 1996 Small, but from a public health
(Tier I, III) anxiety and suicidal perspective relevant ES (0.15–
tendencies: CBI s-b 0.27), not long-living
prevention and symptom CBT may be more effective for
reduction in students families with middle to high
aged 11–19 socioeconomic status
(R) Indicated > universal
prevention
Maag, Swearer, and Depression: s-b CBI 20 1970–2007 Larger effects for short-term
Toland (2009) treatment for children interventions: weaker ES
and adolescents (0.13) for 10 or more weeks,
(MA) stronger ES (0.54) for 8 or
less weeks
Mychailyszyn, Brodman, Anxious and depressed 63 1990–2009 Moderately effective anxiety
Read, and Kendall (2012) youth: interventions interventions (medium ES
(Tier I–III) (MA) Hedge’s g = 0.50)
Mildly effective depression
interventions (small-to-
medium ES g = 0.29)
Effects not persist over time
(1 year)
Nehmy (2010) Depression and anxiety: Depression 19 2001–2010 Only two studies showed a
(Tier I–III) s-b prevention for preventive effect, eight
adolescents (focus on studies a treatment effect
Australia) Anxiety: 9 1999–2010 Only two studies with
preventive effect, but six with
treatment effect
Summarised: No overwhelming
preventive effects
More consistent and promising
treatment effects in
adolescent mental health
Spence and Shortt (2007) Depression: s-b universal 14 Up to July 2006 Insufficient evidence:
(Tier I) prevention among inconsistent and small effects
children and adolescents between 6 and 11 months
(R) after intervention, no benefits
in long-term
Need for family components
incorporation
Small, significant short-term
benefits for targeted
prevention
(c) Externalising disorders
Agabio et al. (2015) Alcohol and drug 65 1968–2015 Some evidence in single
(Tier II) prevention programmes, best
effectiveness in Europe was
for ‘Unplugged’ (Table 3b)
DuPaul et al. (2012) ADHD: CM, CBI and 60 s-b 1996–2010 Overall, moderate to large ES
academic interventions (from 264) for behaviour measures for
(MA) w-s (0.72) and s-s (2.20)
designs. CM (w-s) and CBI
(s-s) are superior for
behaviour outcomes
Significant ES (3.48) for
academic outcomes for s-s
designs. Academic
interventions were associated
with greater academic
outcomes
Emmers, Bekkering, Overview of systematic 21 (9 school 2000–2012 Small positive effects of s-b
and Hannes (2015) reviews on alcohol and based) prevention programmes,
(Tier I–III) drug misuse in better results with affective-
adolescents based and peer-provided
(MA) programmes
(continued)

Table 2 (continued)
n Studies
Flynn, Falco, and Independent (of 6 RCTs were 1991–2011 Small ES, little effectiveness of
Hocini (2015) developers) evaluation of suitable widely used programmes
(Tier I) drug misuse programmes from 5071
(R) publications
Gottfredson and Wilson Substance (alcohol or 94 n/a CBT prevention at high-risk
(2003) other drug) abuse: s-b (0.2) > universal
(Tier I, III) prevention activities interventions (0.05)
(MA) Increased effectiveness for
middle school age. Peers-
alone delivery is most
effective. Short programme
duration (<4.5 months) is
sufficient
Hahn et al. (2007) Externalising, violent and 53 Prior to Decreased violence among
(Tier I–II) aggressive behaviour: December school-aged children at all
universal s-b prevention 2004 grade levels
(R) Overall median effect: 15%
reduction in violent behaviour
Hennessy and Tanner- Brief s-b interventions for 17 1990–2012 Effectiveness of individual
Smith (2015) alcohol use prevention in interventions, group
(Tier II–III) adolescents programmes not effective,
(MA) advantages for motivational
enhancement therapy
Mytton et al. (2006) Violence: s-b secondary 56 1861–2003 Significant reduction in
(Tier II–III) prevention aggressive and violent
(MA) behaviour in 34 studies
(pooled ES = 0.41)
Benefits in primary and
secondary school
Improving relationships or
social skills > teaching skills
of nonresponse to provocative
situations
Park-Higgerson, Violence: Evaluation of s-b 26 Mild effect (0.15) of focused
Perumean-Chaney, prevention programmes single-component
Bartolucci, Grimley, (MA) approaches (compared with
and Singh (2008) multiple-approach
programmes) on reduction in
s-b violence
Pelham, Wheeler, and ADHD: treatment 31 in 1972–1996 BPT and BCM in the classroom
Chronis (1998) (R) classroom meet criteria for empirically
setting well-established treatments
CBI does not meet criteria for
well-established or probably
efficacious treatments
Pelham and Fabiano (2008) ADHD: treatment 22 in 1997–2006 Evidence-based treatments:
(R) classroom BPT, BCM and behavioural
setting peer interventions
Reid, Trout, and ADHD: Analysis of self- 16 predominantly 1974–2003 Large ES on on-task behaviour
Schartz (2005) regulation interventions school settings (1.61), inappropriate
(4 types: self-monitoring, behaviour (1.26), academic
self-monitoring plus accuracy and productivity
reinforcement, self- (1.32)
management and self- Limited interpretability: high
reinforcement) variability in ES across
(MA) studies; mixing of ES
calculation; primary age
range 7–13; only 5.8% girls (3
from 51); little or no
diagnostic information on
ADHD diagnosis
(continued)

Table 2 (continued)
n Studies
Tobler et al. (2000) Drug: s-b universal 207 1978–1998 Noninteractive programmes
(Tier I) prevention programmes (knowledge presentation, no
(MA) peer communication)
ES = 0.05
Interactive programmes
(including peer group
discussions) ES = 0.15
Trout, Lienemann, ADHD: nonmedication s-b 41 1963–2004 Modest ES (0.25) for
Reid, and treatment on academic antecedent studies
Epstein (2007) performance (e. g., math, Lower noise levels may reduce
(Tier III) reading) error rates. Interventions that
(R) directly address academics
(e.g. strategy instruction,
remedial tutoring) are
effective
Large ES (1.22) for
consequence-based and
parent- and peer-mediated
studies
Token reinforcement and
response cost were highly
effective in increasing the rate
of responding, work
completion and overall
accuracy of academic
responding
Wilson et al. (2001) Problem behaviour (crime, 165 Not specified Large heterogeneity of effects
(Tier I–III) substance use, dropout/ across studies
nonattendance and other s-b prevention appears
conduct problems): s-b effective with overall small ES
prevention in reducing targeted problem
(MA) behaviour
Negative effects for non–
cognitive–behavioural
counselling and social work.
Positive effects for cognitive–
behavioural and behavioural
methods programmes
Environmentally focused
interventions particularly
effective for reducing
delinquency and drug use
Wilson and Aggressive and disruptive 249 Since 1950 Positive and significant mean
Lipsey (2007) behaviour: s-b effects on all outcome
interventions variables (ES = 0.20–0.35)
(MA) Decrease in aggressive/
disruptive behaviour in
universal programmes
(ES = 0.21) and in selected/
indicated programmes
(ES = 0.29)
ADHD, attention-deficit hyperactivity disorder; BCM, behaviour contingency management; BPT, behavioural parent training; b-s,
between subjects design; CBT, cognitive–behavioural treatment; CBI, cognitive–behavioural interventions; CM, contingency
management; DRC, daily report cards; ES, effect size; MA, meta-analysis; n/a, not applicable; MHP, mental health problem; PND,
score, percentage of nonoverlapping data points; R, review; s-b, school-based design; s-s, single subject design; w-s, within-subjects
design; <, worse than; >better than.
(2004). There are a number of universal, selective & Collier, 2012), crime prevention (Public Safety
and indicated prevention programmes for various Canada, 2009), trauma (Foa, 2009), eating disorders
disorders: conduct disorders (Eddy, 2005), depres- (Hosman, 2005), substance use disorders (Anderson,
sion (Jane-Llopis, Mu~
noz, & Patel, 2005; Neil & Biglan, & Holder, 2005; Killackey, McGorry, Wright,
Christensen, 2007), anxiety disorders (Campbell, Harris, & Jurianz, 2005), psychotic disorders (Kil-
2003; Hosman, Dadds, & Raphael, 2005; Neil & lackey & Yung, 2007) and suicide prevention (Hos-
Christensen, 2009), bullying (Jones, Doces, Swearer, man, Wasserman, & Bertelotte, 2005). Evidence-

Table 3 Examples of school-based programmes. The Table is organised in three parts: (a) Examples of universal SBP programmes
(Tier I), (b) Examples of selective SBP programmes (Tier II), (c) Examples of indicated (Tier III) and treatment programmes
Type of disorder Programme Developed/trialled Sample age
(a) Examples of universal SBP programmes (Tier I)

Externalising GBG, Good Behaviour Game (Kellam, Rebok, United States 6–12
(Aggressive Ialongo, & Mayer, 1994)
Behaviour & ICPS, I Can Problem Solve (Shure, 1997) United States 4–12
Conduct Disorder) PATHS, Promoting Alternative Thinking United States Primary
Strategies (Greenberg, Kusche, Cook, & school age
Quamma, 1995)
OBPP, Olweus Bullying Prevention Programme EU 7–18
(Olweus, 1989)
FAST TRACK (Conduct Problems Prevention United States 3–8
Research Group, 2007)
Depression RAP, Resourceful Adolescent Programme Australia 12–15
(Shochet et al., 2001)
BeyondBlue Schools Programme (Burns & Hickie, Australia 12–18
2002; Sawyer et al., 2010; Spence et al., 2005)
FRIENDS (Barrett et al., 2000; Stallard et al., Australia 6–16
2005)
MoodGYM (O’Kearney et al., 2006) Australia 13–17
PPP, Penn Prevention Programme – Australian Australia 7–17
Version (Pattison & Lynd-Stevenson, 2001)
PSFL, Problem Solving For Life (Spence, Sheffield, Australia 12–15
& Donovan, 2003)
PRP, Penn Resiliency Programme (Cutuli, United States 7–17
Chaplin, Gillham, Reivich, & Seligman, 2006)
Anxiety FRIENDS (Barrett & Turner, 2001; Lowry-Webster Australia 6–16
et al., 2003; Stallard et al., 2005)
MoodGYM (Calear, Christensen, Mackinnon, Australia 13–17
Griffiths, & O0 Kearney, 2009)
PC, Positive Communication (Garaigordobil, EU 12–14
Maganto, P erez, & Sansinenea, 2009)
PSFL, Problem Solving for Life (Sheffield et al., Australia 14–15
2006)
PTP, Positive Thinking Programme (Rooney et al., Australia 8–9
2006)
Substance use LST, Life Skills Training (Botvin, 2000) United States 10–15
ALERT (Ellickson, McCaffrey, Ghosh-Dastidar, & United States Adolescents
Longshore, 2003)
Unge & Rus (Strom et al., 2015) EU 13–16
(b) Examples of selective SBP programmes (Tier II)
Externalising (Aggressive IYS, Incredible Years (Barlow, 2007; Webster- United States 2–8
Behaviour & Conduct Stratton & Reid, 2003)
Disorder) Anger Coping Programme (Lochman, Nelson, & United States 9–12
Sims, 1981)
Depression FRIENDS (Barrett et al., 2000; Stallard et al., Australia 7–16
2005)
Classroom-based CBT (Stallard et al., 2013) 12–16
Anxiety PENN Prevention (Roberts, Kane, Thomson, USA 11–13
Bishop, & Hart, 2003)
The Queensland Early Intervention and Australia 7–14
Prevention of Anxiety project (Dadds, Spence,
Holland, Barrett, & Laurens, 1997)
FRIENDS (Barrett et al., 2000; Dadds et al., 1997; Australia 7–16
Lowry-Webster et al., 2003)
HHMI, Hero Heroine Modeling Intervention Puerto Rico 12–15
(Malgady, Rogler, & Costantino, 1990)
PTCBI, Personality-Targeted Cognitive– United Kingdom 13–16
Behavioural Intervention (Castellanos & Conrod,
2006)
Substance & Alcohol Brief, personality-targeted interventions (Conrod, United Kingdom 13–16
Abuse Castellanos-Ryan, & Strang, 2013)
Brief intervention (Winters, Fahnhorst, Botzed, United States 12–18
Lee, & Lalone, 2012)
‘Unplugged’ (van der Kreeft, 2009; Vigna-Taglianti EU 12–14
et al., 2014)
(continued)

Table 3 (continued)
Type of disorder Programme Developed/trialled Sample age
(c) Examples of indicated (Tier III) and treatment programmes

Externalising (Aggressive First Step to Success (Walker et al., 1998) United States 2–5
Behaviour & Conduct Fast Track (Conduct Problems Prevention United States 6–11
Disorder) Research Group, 2007)
PEP-TE (Plueck et al., 2015) EU 3–6
Art Room (Cortina & Fazel, 2015) EU
Depression Coping with Stress Course (Clarke et al., 1995) United States 13–18
FRIENDS (Barrett et al., 2000; Koesters, Australia 7–16
Chinapaw, Zwaanswijk, van der Wal, & Koot,
2015; Stallard et al., 2005)
ACE, Adolescents Coping with Emotions Australia 13–16
(Kowalenko et al., 2005)
IPT-AST, Interpersonal Psychotherapy – United States 11–16
Adolescent Skills Training (Young, Mufson, &
Davies, 2006)
Anxiety Coping Cat / C.A.T. Project (Flannery-Schroeder United States 8–13/14–17
& Kendall, 1996; Khanna & Kendall, 2008)
Canadian Adaptation: Coping Bear (Connolly,
Bernstein, & The Work Group on Quality Issues,
2007)
Australian Adaption: Coping Koala (Barrett,
Dadds, & Holland, 1994)
FRIENDS (Barrett et al., 2000; Dadds et al., 1997; Australia 7–16
Koesters et al., 2015; Lowry-Webster et al.,
2003; Stallard et al., 2005)
COOL KIDS (Mifsud & Rapee, 2005) United States 8–11
PRP, Penn Resiliency Programme (Brunwasser United States 8–15
et al., 2009)
ACE, Adolescents Coping with Emotions Australia 14–15
(Sheffield et al., 2006)
BRAVE (Spence et al., 2006) Australia 8–12, 13–17
ASD Whalon, Conroy, Martinez, and Werch (2015) United States 3–12
PTSD ESPS (Berger, Gelkopf, Heineberg, & Zimbardo, Israel 8–11
2015)
Bounce Back (Langley, Gonzalez, Sugar, Solis, & United States 5–10
Jaycox, 2015)
based Tier I, Tier II and Tier III mental health I Penn Resiliency Programme (PRP; Brunwasser,
interventions in schools are listed in Neil and Chris- Gillham, & Kims, 2009; Gillham, Reivich, Jaycox,
tensen (2009), Christensen et al. (2011) and in & Seligman, 1995) were not replicated by a large
O’Connell et al. (2009). Integrated models generally Dutch Study (Tak, Lichtwarck-Aschoff, Gillham, Van
reduce systematic overload and maximise sustained Zundert, & Engels, 2016) in adolescents.
yield (Fixsen, Naoom, Blase, Friedman, & Wallace, There is only limited evidence for early intervention
2005). It is, however, not recommended to combine programmes targeting suicide and suicide-related
various prevention programmes in an uncoordinated behaviour in school settings. Robinson et al. (2013)
manner (Gottfredson & Gottfredson, 2002; Sugai & analysed 43 studies, 15 universal awareness pro-
Horner, 2006). grammes, 23 selective, 3 targeted and 2 post inter-
Greenberg et al. (2001) reviewed 35 effective vention trials.
school- and community-based prevention pro- Teesson, Newton, and Barrett (2012) identified
grammes for adolescents. ‘The Safe Communities seven Australian programmes for preventing alcohol,
Safe Schools Programme Guide’ offers further infor- cannabis and tobacco misuse that were mainly
mation on effective school- and community-based based on early intervention and social learning.
prevention programmes (Center for the Study and A number of school-based, interactive, computer-
Prevention of Violence, 2002). Neil and Christensen or Internet-based prevention programmes have been
(2007) performed a systematic review of Australian developed and deployed in school settings, e.g.
SBP and early intervention programmes for anxiety against smoking (Andrews et al., 2014; Cremers,
and depression (six universal programmes, two Mercken, Oenema, & de Vries, 2012; Sussman,
indicated interventions and one treatment pro- 2002), alcohol (Korczak, Steinhauser, & Dietl,
gramme), based on cognitive behavioural (CBT), 2011; Shakeshaft et al., 2014) and/or drug misuse
interpersonal therapy or psycho-education. The (Champion, Newton, Barrett, & Teesson, 2013; Wil-
small effects of preventing depression using the Tier liams, Grifin, Macaulay, West, & Gronewold, 2005),

obesity (Ajie & Chapman-Novakofski, 2014; Jones et al., 2015). Tier I interventions despite their advan-
et al., 2014; Mauriello et al., 2006; Verrotti, Penta, tages may not provide sufficient intensity, specifica-
Zenzeri, Agostinelli, & De Feo, 2014), anxiety and/or tion or duration to be effective for children ‘at risk’.
depression (Davies, Morriss, & Glazebrook, 2014;
Khanna & Kendall, 2008; Spence, Holmes, & Dono- Tier II: selected prevention. Selected interventions
van, 2006) and violence (Bossworth, Espelage, cater to children at risk for MHP. Manifest clinical
DuBay, Dahlberg, & Daytner, 1996). Results indi- symptoms are not yet present, but there are clear-
cate that the majority of these programmes are cut biological, psychological and social risk factors
implemented with high fidelity, efficacious and easily like low family income, exposure to substance
accessible. They are cost effective, are acceptable to use, difficult temperament or specific traumatic
youth, provide widespread dissemination and have experiences. Tier II interventions (Table 3b) often
an early positive impact on various problems. require multigating, multistep and multivariant
Because of space restrictions, we only listed a few screening for identifying individuals at risk of devel-
computer-assisted programmes. Unfortunately, oping MHP. As an example, screening programmes
there is only one review article available on com- and gatekeeper training are reasonably effective
puter-assisted SBI (Champion et al., 2013). against suicidal behaviour (Robinson et al., 2013).
Tier I: universal prevention. Tier I interventions Tier III: indicated prevention. Tier III interventions
cater to students who require support in their social, (Table 3c) cater to individuals with prodromal symp-
cognitive, emotional and behavioural development. toms of mental disorders who do not yet meet full
Interventions mostly include school-based compe- diagnostic criteria. Examples for Tier III programmes
tence enhancement programmes. School adminis- include disruptive behaviour (DB; Bradshaw, Waas-
trators prefer Tier I interventions because these are dorp, & Leaf, 2015), AS (Bellini, Peters, Benner, &
time efficient, broadly applicable, there is no need to Hopf, 2007; Wilkinson, 2014), posttraumatic stress
screen students ‘at risk’ and the risk of stigmatising disorder (Rolfsnes & Idsoe, 2011), major depression
students is low (Horowitz, Garber, Ciesla, Young, & (Brown, Pearson, Braithwaite, Brown, & Biddle,
Mufson, 2007). Universal prevention programmes 2013; Calear & Christensen, 2010), anxiety, sub-
are positive, proactive and readily accepted (Rutter, stance misuse (Mytton, DiGuiseppi, Gough, Taylor,
1993). Targeting multiple risk factors simulata- & Logan, 2006), suicidal behaviour (Kavanagh et al.,
neously, Tier I programmes are effective and effica- 2009) and violence. Interventions aiming at reducing
cious (Domitrovich et al., 2010). They target varied self-harm do not provide enough evidence of effec-
problems at a time, tie multiple resources, and may tiveness (Miller, 2013).
reduce comorbid pathology (Weisz et al., 2005). Indicated programmes were developed for children
Typical examples for Tier I interventions (Table 3a) with clinically significant MHP who require highly
are a programme for social and emotional learning specialised care and have failed to benefit from
(Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, universal or selected interventions. Parents can be
2011) or universal interventions against externalis- offered parent group trainings (Mendez, Ogg, Loker, &
ing behaviour (Hahn et al., 2007). Furthermore, Fefer, 2013). Finally, Tier II and III interventions
universal SBP programmes are effective in preventing produce larger ES than Tier I interventions (Bradshaw
child sexual abuse and neglect (Brassard & Fiorvanti, et al., 2015; Cowen, 2014; Mendez et al., 2013).
2015; Walsh, Zwi, Woolfenden, & Shlonsky, 2015),
substance use [cannabis, tobacco and alcohol
(Champion et al., 2013)] and anxiety disorders (Lau Treatment
& Rapee, 2011). Two convincing Australian health
Prevention specifically indicated prevention and
prevention programmes are the ‘Beyondblue Schools
treatment effects (Table 3c) are not always clearly
Research Initiative’ for preventing depression in
differentiated: Horowitz et al. (2007) emphasised
students (Sawyer et al., 2010; Spence et al., 2005)
that ‘prevention effects’ are characterised by a dete-
and FRIENDS, a cognitive–behavioural prevention of
rioration of symptoms over time in the control group
anxiety programme that focuses on emotional regu-
compared with no or reduced worsening in the
lation, thinking styles and coping mechanisms (Bar-
intervention group, whereas ‘treatment effects’ are
rett, Webster, & Turner, 2000; Dadds et al., 1997;
characterised by an improvement in the intervention
Lowry-Webster, Barrett, & Lock, 2003; Stallard
group compared with significantly less or no changes
et al., 2005). Suicides (Miller, 2011), suicide
in the control group.
attempts or physical fighting decrease with universal
prevention and may, therefore, have a public health Applying SBI includes the following:
impact, weak statistical effects notwithstanding. 1. identifying target problems and population,
Although a combination of various programmes is 2. selecting an appropriate treatment programme,
usually not recommended because of interacting 3. implementing the programme, and
effects, implementing evaluated combined universal 4. evaluating the programme and maintaining achi-
prevention approaches may be advantageous (Cook eved effects.

Identifying target problems and population. Tar- saving system or by making response costs trans-
get problems usually cover behavioural, learning, parent.
psychic and psychosocial problems of the students.
If various problems are identified, these should be Teacher–parent relationships: Parent-based inter-
hierarchically classified, and a maximum of three ventions aim at changing school-based behaviour
top items selected. As concerns the targeted popu- problems by strengthening the parent–school alli-
lation, the whole school (e.g. for bullying), a class ance and partnership (Carlson & Christenson, 2005;
(e.g. for improving classroom behaviour) or single Ysseldyke et al., 2006).
students (e.g. ADHD or learning disorders) may be Teachers usually contact parents for their chil-
attended (Table 1). dren’s social, disruptive or emotional behaviour
problems. Instead of this reductionist concept of
Selecting an appropriate programme. There are parent involvement, a two-way exchange of informa-
established and evaluated programmes targeting tion will strengthen the collaboration between par-
various problem areas (Tables 2 and 3). Selecting ents and teachers. Parents will feel more motivated
an appropriate programme will depend on the tar- to support their children and cooperate with SBI if
geted problem, the availability of resources and of their relationship with the school is strong and based
qualified internal or external therapists (e.g. teach- on mutual respect (Carlson & Christenson, 2005;
ers and healthcare professionals), the theoretical Cox, 2005; Ysseldyke et al., 2006).
basis of the programme (e.g. targeted risk and Parental training is an important part of SBI (Men-
protective factors) and its demonstrated efficacy dez et al., 2013). Persisting manifest or hidden con-
(Fazel, Hoagwood, Stephan, & Ford, 2014; Haggerty, flicts between parents and teachers will endanger a
McGlynn-Wright, & Klima, 2013). programme’s success. Collaboration and continuing
communication between all involved persons, e.g.
Programme implementation. School-based inter- using daily report card (DRC), will help in improving a
ventions require motivation, cooperation and coor- child’s behaviour. Unfortunately, there is only limited
dination of all involved persons. Barriers must be qualitative research available about specific school-
overcome by careful planning, by providing the based techniques and the various modes for estab-
necessary means, full information, and staff train- lishing and maintaining a fruitful relationship
ing, and by creating a positive, cooperative climate. between teachers and parents (Cox, 2005).
Specifically, teacher–parent–health service–student
relationships will strongly influence a programme’s Teacher–student relationships: A trustworthy and
efficacy and acceptance. confidential relationship between teachers and stu-
Most evaluated successful programmes are based dents and a positive atmosphere in the classroom are
on (cognitive) behavioural methods (Tables 2 and 3). important prerequisites for successful SBI. Imple-
Their success will mostly depend on motivational menting clear and stringent rules, valuing strengths
aspects, clearness and suitability to actual needs. and fostering resources of the students, identifying
In the following, we will discuss personal- and and naming incorrect conduct and demanding cor-
programme-related aspects of programme imple- rect behaviour will result in positive effects. Positive
mentation and zoom in on ADHD-related SBI as an motivation and student-friendly teaching techniques
example. like errorless learning (Warmington, Hitch, & Gather-
cole, 2013) will help in grounding the basis for a
Intervention base: teachers and teacher–student– fruitful collaboration in SBI.
parent relationships. Teachers: A teacher’s per-
sonality, experience, occupational stress, specific Interventions: cognitive–behavioural approaches.
programme training, access to professional advice Behavioural (e.g. DRC) and cognitive–behavioural
and other important prerequisite factors (Commit- interventions (CBI) predominate in school-based
tee on School Health, 2004) will strongly influence treatments and psychotherapy. CBI will focus on
the success of SBI. However, organisational inter- changing dysfunctional thoughts, managing emo-
ventions, such as stress management training, yield tions and preventing or reducing dysfunctional
only minimal effect sizes (Nagieh, Montgomery, behaviour. Examples include techniques for improv-
Bonell, Thompson, & Aber, 2015), possibly because ing behaviour, problem recognition and solving, self-
committed teachers usually are resilient and rela- regulation and managing emotions (Kendall &
tively stress resistant. Teachers usually are only Hedtke, 2006; Mennuti & Christner, 2012). Finally,
insufficiently informed about their students’ MHP improvements must be stabilised, generalised and
(Gowers, Thomas, & Deeley, 2004). They should, transferred to other environments.
therefore, be instructed and prepared to understand Meta-analyses found ‘moderate positive effects for
the background of the problem behaviour and how to treatments administered in school settings’ (Weisz
handle it. Methods are, e.g. reinforcing favourable et al., 2005). Cognitive–behavioural SBI programmes
behaviour, implementing behavioural plans, a token that implement strategies for modifying behaviour

yield concordant favourable effects and help in reduc-

Implementing SBI
ing problem behaviour (Wilson, Gottfredson, &
As mentioned earlier, the success of a SBI depends on
Najaka, 2001; Wilson et al., 2003).
carefully selecting an appropriate programme, provid-
Computerised CBT improves the availability of evi-
ing the necessary resources, and on carefully prepar-
dence-based interventions but is still in its early stages.
ing, performing and evaluating the programme. This
The interactive programme, ‘Think, Feel, Do’ (Attwood,
includes answers to the following three main questions
Meadows, Stallard, & Richardson, 2012), a CBT for
(Fixsen & Ogden, 2014): what should be implemented,
reducing anxiety and mood problems, and ‘MoodGYM’
how should the programme be implemented and who
(ANU Institute for Mental Health Research, 2004;
should implement, support and evaluate it.
O’Kearney, Kang, Christensen, & Griffiths, 2009;
O’Kearney, Gibson, Christensen, & Griffiths, 2006), a 1. What should be implemented:
CBT programme for improving depression, attribution Selecting an established and proven programme
style and self-esteem. MoodGYM, is recently revised. A that targets identified problems (Table 3) will
systematic review of 12 articles on computer-based provide a sound basis for treatment.
mental health programs proved enhanced knowledge
about depression, reduced symptoms and less stigma- 2. How should the programme be implemented:
tisation (Griffiths & Christensen, 2007). Olin, Saka, Crowe, Forman, and Hoagwood (2009)
listed detailed information on 29 frequently advo-
Interventions for ADHD. Attention-deficit/hyper- cated, evidence-based SBI. For implementation, a
activitydisorderwith its clinical variants and comorbid systemic approach that respects the opinions of
conditions is associated with multiple impairments all participants will be advantageous. ‘Good out-
within the school context, such as academic under- comes (. . .) occur when effective practices are
achievement, inappropriate behaviour and poor peer implemented effectively’ (Fixsen et al., 2005).
relationships (Barkley, 2006). ADHD and related
affective instability are sometimes not sufficiently 3. Who should implement, support and evaluate the
controlled by medication, office-based psychotherapy programme:
or psychosocial treatments. Selecting experienced, qualified staff for providing
There are established SBI for ADHD: Behaviour motivation, sensibility and knowledge is a decisive
classroom management is widely available in step in the implementation process. In addition,
school settings (Gottfredson & Gottfredson, 2001). the trainers must be coached and supervised for
The ‘Clinical practice guideline for the diagnosis, preparing, training, performing the intervention,
evaluation and treatment of ADHD in children and dealing with unexpected problems and conflicts,
adolescents’ (AACAP Council, 2007) of the Ameri- and finally evaluating the whole process (Fixsen
can Academy of Pediatrics highly recommends et al., 2005; Fixsen & Ogden, 2014).
teacher- and/or parent-administered behaviour
therapy (BT) as first-line treatment for preschool Reviewing the literature, we found moderate to
children. Teacher-administered BT is also strongly major effect sizes for many SBI (Tables 2 and 3).
recommended for elementary school children with Clinical research has often neglected the implemen-
ADHD. Because treatment should be provided tation process, i.e. the transfer of evidence-based
already in the early school years, the AAP guideline interventions from research into the real school
does not include SBI programmes for adolescents context. As a consequence, programme performance
(age 12–18 years). may be endangered (Green, 2012).
The ADHD practice guideline of the Canadian Gottfredson and Gottfredson (2002) examined the
Attention Deficit Hyperactivity Disorder Resource implementation quality of SBP in daily practice and
Alliance - CADDRA (2011) provides an important compared the results to those of the initial study. They
resource (‘Educational accommodation letter tem- found that half of the prevention programmes and
plate’, p. 46) and should be implemented in collab- only a fourth of the mentoring programmes realised
oration with the parents. CADDRA also recommends the number of sessions specified in the research-
DRC for improving the communication between based curricula. Only between 47% and 78% of the
school and home for monitoring behavioural change. routine programmes (depending on the type of pro-
The National Institute for Health and Clinical Exc- gramme) were followed for longer than 1 month.
ellence - NICE (2008) mentioned in its clinical guide-
line 72 on ADHD that ‘teachers who received training Standards of evidence
for ADHD and its management should provide
behavioural interventions in the classroom to help Flay et al. (2005) described standards of evidence for
children and young people with ADHD’ (p. 10 and efficacy, effectiveness and dissemination.
p. 27). Examples include the widely used Behaviour Criteria of efficacy include accurate instructions, a
Classroom Management (Gottfredson & Gottfredson, randomised controlled study design and a thor-
2001) and other effective SBI programmes (cf. Table 2c oughly controlled programme evaluation, allowing
and Pfiffner, Barkley, & DuPaul, 2006). others to implement and replicate the programme.

Evaluation should be based on data collected by contrasts with the multiple limitations encountered
people not involved in the intervention and include in everyday practice:
calculating measures of outcome, follow-up, fre-
1. extensive local planning, involving all related
quency and severity of undesired effects, describing
persons in decision-making,
practicability and estimating effect sizes, construct
2. employing regular school staff as trainers,
validity and reliability.
3. integrating the programme into the regular school
Criteria of effectiveness include all criteria for
activities,
efficacy plus additional training and technical sup-
4. organisational support for training and supervi-
port (e.g. manuals), interpreting comprehension or
sion and
conjecture of causal mechanisms and estimating
5. standardised programme materials.
integrity, adherence and involvement of the target
audience. Further criteria are generalisation, practi- Schools should develop an in-house organisational
cal values and replication of the findings. structure for facilitating the implementation of
Criteria of broad dissemination include all criteria proven strategies.
for effectiveness plus standardised training and Evans, Murphy, and Scourfield (2015) identified
technical assistance, providing the necessary infras- four key intervention points contributing to the vari-
tructure, conditions needed to support adoption, ability of implementation: training (increasing knowl-
implementation and sustainability of the pro- edge about the programme), assessment (intervention
gramme, including data on programme costs, and evaluation), clarification (providing knowledge to the
prepared tools for programme monitoring and people executing the programme) and responsibility
evaluation. (individual accountability for sustainable delivery).
Financial and policy constraints. School-based

Factors influencing the implementation process
interventions are usually implemented under finan-
Factors related to the implementation may be as cial and organisational constraints like reduced
important as the selection of an appropriate evi- resources or administrative and operational resis-
dence-based SBI. Forman and Barakat (2011) tance. It is, therefore, indispensable knowing in
extracted five factors influencing the implementation advance whether an SBI can be performed under
of new programmes in the school setting: restricted resources.
1. organisational structure of the school,
Collaboration of various disciplines. To date, there
2. programme characteristics,
is only limited collaboration and communication
3. integration into school goals, policies and pro-
among the persons involved in SBI for child mental
grammes,
health: e.g. teachers, psychologists, child and ado-
4. training/technical assistance and
lescent psychiatrists. In addition, other education
5. administrative support.
professionals and school staff play important roles
The importance of these factors may vary depend- (cf. Table 1).
ing on variables like kind of intervention (Tier I, II or The involved persons are confronted with various
III prevention or treatment). The quality of imple- social, emotional and behavioural problems of stu-
mentation of a mental health prevention and early dents. There are various concepts of disorders (cat-
intervention programme in Australia was associated egorical or dimensional vs. educational framework
with a gain in academic performance equivalent to models), interventions (psycho- and pharmacother-
additional 6 months of schooling by year 7, inde- apy vs. educational interventions) and types of
pendent of the socioeconomic background (Dix, Slee, funding (health insurance vs. disabilities education
Lawson, & Keeves, 2012). act). Behavioural interventions are commonly used
The Institute of Education Sciences (2008) framed in classroom settings although the specificity and
‘What Works Clearinghouse’ (http://ies.ed.gov/ accuracy of their implementation vary and may be
ncee/wwc) to provide information on research about influenced by limited resources (Atkins et al., 2008;
educational interventions. There is an excellent Gottfredson & Gottfredson, 2001). Collaboration
practice guide available, ‘Reducing Behaviour Prob- between and mutual appreciation of the various
lems in the Elementary School Classroom’. This involved disciplines will facilitate the transfer of
practice guide is based on learning theory and aims evidence-based treatments into the daily routine.
at instructing elementary teachers in strategies for
preventing undesirable and intricate behaviour. Key opinion leader teachers. Atkins et al. (2008)
‘What Works Clearinghouse’ described 55 interven- exemplified the important role of key opinion leader
tions and identified 28 interventions as ‘not meeting (KOL) teachers. These teachers are consulted when it
evidence standards’. comes to advising students with academic or beha-
Gottfredson and Gottfredson (2002) identified vioural problems. If both, KOL teachers and mental
multiple programme factors influencing the quality health providers, support the classroom teachers
of implementation because the effectiveness of SBI (instead of only mental health providers), the self-

reported use of recommended intervention strategies sustained compared to the control DB group at 2-
by the classroom teacher would increase. year follow-up. The authors concluded that the SBI
did not result in sustained improvements. Possibly,
Gold standard. Although there exist various stan- booster sessions, continued evaluation or additional
dards and guidelines, e.g. of the American Academy interventions could have helped maintaining initial
of Pediatrics, the National Association of School effects (Pelham & Fabiano, 2008, p. 204). Because
Nurses, the American School Counsellor Associa- long-term effects of behavioural interventions were
tion, the National Association of School Psycholo- only rarely assessed, studies focusing long-term
gists and the National Association of School Social effects are strongly needed.
Workers (Brener et al., 2007), no ‘gold standard’ for
school-based mental health programmes has Transfer (generalisation over settings). Effective
emerged until now. There are only a few studies behavioural interventions are implemented in defi-
analysing single effects of SBI elements. Important nite settings and contexts (home, school and leisure
context factors, such as academic commitment, time). Successful home- and family-focused inter-
classroom and school climate, are usually not con- ventions may not consistently be generalised and
sidered as predictors or modifiers nor as robust and transferred to other environments (McNeil, Eyberg,
sensible indicators of change (Hoagwood et al., Eisenstadt, Newcomb, & Funderburk, 1991). Trans-
2007). fer of improvements to other settings and environ-
ments, therefore, must accurately be planned and
Implementation barriers and constraints. Imple- evaluated.
menting an SBI, there usually are geographical,
economical and sociocultural barriers, transport Practical implications
and financial constraints, as well as limited time
Selecting a programme. Selecting an appropriate,
resources for staff training (Bellini et al., 2007). Fears
effective, evidence-based or best practice programme
of embarrassment and stigmatisation are the most
(Greenberg et al., 2001; Institute of Education
common barriers indicated by young people seeking
Sciences, 2008; Olin et al., 2009) attention should
mental health support (Davidson & Manion, 1996).
be paid to:
Additional barriers include financial constraints,
restricted time for interventions in the daily routine, 1. clarifying assignment: what intervention should
personal beliefs of the school staff about the inter- be implemented by whom with what targets?,
vention and competition with already established 2. targeting problem behaviour,
school priorities (Forman, Olin, Hoagwood, Crowe, & 3. defining the level of intervention: prevention
Saka, 2009). A major issue is confidentiality. Confi- (universal, selected, indicated) or treatment,
dentiality of mental health information is protected 4. including diagnostics: in case of prevention, assess
by law and should be of utmost concern for all identified baseline variables or characterise the
involved persons (Committee on School Health, targeted ‘risk group’; in case of treatment, observe
2004). students directly and systematically and use
Another constraint is the relationship with (exter- behavioural analysis,
nal) medical or psychological services. According to 5. defining the level of implementation (national,
the Committee on School Health (2004), there are state, school district, school-wide, classroom-
three models of cooperation: based, group, individual),
6. defining student and staff population,
1. school-supported mental health models (school
7. considering specific particularities of the school
staff performs the intervention),
setting or level, and compatibility with the
2. community connection models (there are formal
school’s mission statement and
links to external providers),
8. considering available financial resources.
3. comprehensive, integrated models.
Starting programme implementation. Factors pro-

Maintaining achieved effects and evaluating the moting the success of programme implementation
programme include the following:
Sustainability (generalisation over time). School- 1. providing programme-related support to all involved
based psychological services are focused on satisfy- persons including KOL teachers and sceptics,
ing immediate concerns (Allen, 2011). Therefore, 2. appreciating the value of and commitment to
usually no long-term effects are expected. Shelton change,
et al. (2000) prospectively studied preschool chil- 3. deciding on the most adequate treatment pro-
dren with a high level of DB at kindergarten entry. gramme,
The children received a classroom-based behaviour 4. providing sufficient time for staff training,
intervention lasting for the first year that resulted 5. complying with implementation requirements
in behavioural improvement but was not (e.g. school organisation and costs),

6. considering factors like teacher turnover or pos- (DuPaul, Eckert, & Vilardo, 2012)? In order to
sible deficit-oriented perspectives, achieve more effective SBI, active collaboration
7. fostering school–family relationships with regard to between researchers and practitioners is needed
mutual respect and collaboration providing infor- (Weisz et al., 2005).
mation on all programme components and identi- Research is mainly needed in:
fying essential components of success,
1. verifying programme efficacy for a range of tar-
8. supporting programme implementation does the
geted problem behaviours using appropriate
programme fit into the actual school context, and
research designs, e.g. randomised controlled tri-
9. avoiding simultaneous implementation of differ-
als, and
ent programmes or competition with existing
2. securing efficient programme implementation,
programmes, except for evaluated combinations.
dissemination, sustainability and generalisation
of prevention and treatment programmes.
Guarantee ongoing support. Provide ongoing and
Applying micro-analytic research methods, the
effective support for the programme by the following:
path from research to practice will not be unidirec-
1. providing adequate assistance during the imple- tional. It rather evolves into a bidirectional rela-
mentation phase, tionship between research and practice, called
2. arranging continuous monitoring and supervi- ‘bidirectional translational algorithm’ (Green, 2012,
sion of the trainers and p. 333, italics are original). At this moment, we have
3. providing for booster sessions to ensure long- not reached the ability to treat all children effectively.
lasting effects. SBIs provide essential possibilities to improve
patient-centred care. Research-based interventions
should be transferred into daily practice by a thor-
Programme evaluation. In order to ensure a qual-
oughly planned and evaluated implementation pro-
itatively sound programme evaluation, gather imple-
cess in order to achieve significant progress in SBI.
mentation data, stipulate programme integrity and
fidelity by the following:
1. selecting well-defined items and parameters for Acknowledgements
assessing adequate implementation, This review was invited by the editors of JCPP and has
2. assessing programme effects on primary targeted undergone external peer review. The authors thank
behaviours, additional variables beyond primary Leah Steeb, Eva Maria K€ uhle, Helena St€ uckrad, Mar-
targets and academic achievement, celle Grosz and Monika Nitze, students of psychology,
3. regularly gathering multidimensional and multi- for their help in retrieving literature and for coding
studies. We are grateful to Maja Schramm for English-
informant data under blinded conditions and
language advice and Jonathan Green for most useful
4. regularly providing feedback to all involved per-
comments. The authors declare having no competing or
sons during the implementation phase and there- potential conflicts of interest in relation to this work.
after by evaluating and communicating results.
It often remains unclear why a programme does
not satisfactorily work in everyday practice. The Correspondence
question arises if the underlying problems are Susanne Ohmann, Department of Child and Adolescent
related to missing effectiveness or to implementation Psychiatry, Medical University of Vienna, A-1090
Waehringer Guertel 18-20, Austria; Email: susanne.
problems. Were confounding factors like additional
ohmann@meduniwien.ac.at
medication or external psychotherapy controlled for
Key points
Key practitioner message
• Up to a quarter of school-aged children exhibit mental health problems (MHP); 70–80% of all school-aged
children receive no kind of mental healthcare. Schools can directly identify and serve as a basis for treating
MHP in situ. School-based preventive and therapeutic interventions (SBI) are effective.
• Although considerable positive effects of SBI are observed in general, there is a large range of efficacy and
efficiency of the various programmes depending on the quality of the intervention and its implementation.
• SBIs, e.g. for students with ADHD, yield moderate effects. Factors such as school climate, programme fidelity,
teacher–parent, teacher–health services and teacher–student relationships, quality of the programme
implementation and funding will strongly influence their success.
• Standards concern efficacy, effectiveness and dissemination (Flay et al., 2005). Many factors influence the
implementation of SBI-like integration into the school setting, use of school staff as trainers, organisational
support and collaboration of various disciplines. We recommend four steps for successfully implementing a SBI
programme.

Areas for future research

Concerning SBI programmes
• Identify specific intervention components that can clearly be linked to specific outcomes, focus on SBP
programmes, including skills training, individual CBT and others (De Silva et al., 2013).
• Identify participants’ characteristics and contextual factors as determinants of success and provide follow-up
data to evaluate sustainability and to find out the optimal ‘dose’ of intervention.
• Consider that stronger effects are sometimes not immediately detected following an intervention (sleeper
effects).
• Foster replicating single results and observations by independent researchers promote research on hitherto
neglected MHP.
• Engage in transferring research programmes into daily practice (Erchul & Sheridan, 2014), promote
randomised controlled trials, considering that the scientific ‘gold standard’ for evaluating treatment effects
in SBI is lacking (DuPaul et al., 2012).
• Engage in research on the ‘well-known lack of generalisation and maintenance of gains when behavioural
treatments are withdrawn’ (Pfiffner et al., 2006).
Concerning the implementation process

• To date, the relative importance of key factors for successful implementation and their influence on study
results is poorly understood (Olin et al., 2009).
• Consider that research on SBI outcomes should be supplemented with micro-analytic research on SBI processes.
• Reassess that prevention and treatment programmes should be integrated into complex intervention systems
to neutralise the risk of fragmentation in universal and indicated prevention and targeted clinical services
(Greenberg, 2004).
• Consider missing cost–benefit analyses in naturalistic settings of nearly all programmes.
Attwood, M., Meadows, S., Stallard, P., & Richardson, T.

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Journal of Child Psychology and Psychiatry **:* (2016), pp **–** doi:10.1111/jcpp.

Practitioner Review: School-based interventions in

2000). This definition also includes non-school-based

© 2016 Association for Child and Adolescent Mental Health.

Table 1 School- versus office-based interventions

School based Office based

Setting Complex, natural Initiated

overview are (a) to improve knowledge about SBI, (b)

© 2016 Association for Child and Adolescent Mental Health.

(a) General topics and specific targets or disorders

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

Vreeman (2007) Bullying: s-b-interventions 26 1994–2004 Decreased bullying in 7 of 10

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

Type of disorder Programme Developed/trialled Sample age

(a) Examples of universal SBP programmes (Tier I)

© 2016 Association for Child and Adolescent Mental Health.

Type of disorder Programme Developed/trialled Sample age

(c) Examples of indicated (Tier III) and treatment programmes

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

yield concordant favourable effects and help in reduc-

© 2016 Association for Child and Adolescent Mental Health.

Financial and policy constraints. School-based

© 2016 Association for Child and Adolescent Mental Health.

Starting programme implementation. Factors pro-

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

Areas for future research

Concerning the implementation process

Attwood, M., Meadows, S., Stallard, P., & Richardson, T.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

© 2016 Association for Child and Adolescent Mental Health.

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Journal of Child Psychology and Psychiatry **:* (2016), pp – doi:10.1111/jcpp.