In the preceding chapters, we reported the effectiveness results for the main outcomes of self-reported anxiety and depression. In this chapter, we report the additional outcomes from all studies focusing on anxiety, depression or anxiety and depression.
Additional primary outcomes
Self-reported psychological well-being
Of the 137 studies focused on preventing anxiety, depression, or both depression and anxiety, 15 reported an outcome of self-reported psychological well-being, life satisfaction or quality of life. Five studies reported measuring well-being using the Warwick–Edinburgh Mental Wellbeing Scale,124,126,127,132,133 seven studies reported a measure of life satisfaction124,131,159,181,187,203,239 and two studies reported a quality-of-life measure.129,235 One study reported a measure of social functioning206 and one used the Ryff Scales of Psychological Well-being.143 Planned NMAs by population and setting were not possible; data are reported by outcome measure and study in Table 10. From their model-based analysis, Calear et al.16 reported that there were no differences between interventions for school-led CBT and a waiting list (Cohen’s d –0.08, 95% CI –0.29 to 0.13) or between health service-led CBT and a waiting list (Cohen’s d –0.06, 95% CI –0.21 to 0.09). Using the data reported in the paper, we calculated the difference in mean change from baseline at post intervention, which suggested a small drop in well-being at post intervention. For each of the remaining 12 studies, summary intervention effects were compatible with both an increase and a decrease in well-being/life satisfaction.
| Study | Population | Setting | Comparisona | Results, mean difference (95% CI) |
|---|---|---|---|---|
| Warwick–Edinburgh Mental Wellbeing Scale | ||||
| Calear et al.126 2016 | Universal | Secondary | CBT vs. CBT vs. waiting list | Post intervention: –2.07 (–3.56 to –0.58) |
| Post intervention: –1.09 (–2.32 to –0.14) | ||||
| Calear et al.127 2016 | Universal | Secondary | CBT vs. waiting list | Post intervention: 1.85 (–0.35 to 4.05) |
| Johnson et al.132 2016 | Universal | Secondary | Third wave vs. usual curriculum | Post intervention: 0.01 (–0.12 to 0.14) |
| Johnson et al.133 2017 | Universal | Secondary | Third wave vs. third wave vs. usual curriculum | Post intervention: 0.02 (–0.10 to 0.14) |
| Post intervention: –0.06 (–0.18 to 0.06) | ||||
| Burckhardt et al.124 2015 | Universal | Secondary | Mindfulness/relaxation vs. attention control | Post intervention data not reported |
| Life satisfaction scales | ||||
| Hodas131 2016 | Universal | Secondary | CBT vs. waiting list | Post intervention: 1.74 (–1.28 to 4.76) |
| Khalsa et al.239 2012 | Universal | Secondary | Mindfulness/relaxation vs. usual curriculum | Post intervention: 0.03 (–0.29 to 0.35) |
| Rose et al.203 2014 | Universal | Secondary | CBT + IPT vs. CBT + IPT vs. waiting list | Post intervention: 0.13 (–0.12 to 0.38) |
| Post intervention –0.13 (–0.37 to 0.11) | ||||
| Burckhardt et al.124 2015 | Universal | Secondary | Mindfulness/relaxation vs. attention control | Post intervention data not reported |
| Stallard et al.159 2014 | Universal | Primary | CBT vs. CBT vs. usual curriculum | 12-month follow-up: –0.58 (–1.26 to 0.10) |
| 12-month follow-up: 0.03 (–0.66 to 0.72) | ||||
| Tokolahi et al.181 2018 | Targeted | Primary | Occupational therapy vs. waiting list | Post intervention: –0.45 (–3.39 to 2.49) |
| Seligman et al.187 2007 | Targeted | Tertiary | CBT vs. no intervention | Post intervention: 0.10 (–1.06 to 1.26) |
| Quality of life, social functioning and Ryff Scales of Psychological Well-being | ||||
| Quality of life | ||||
| Gucht et al.129 2017 | Universal | Secondary | Third wave vs. usual curriculum | Post intervention: 0.09 (–0.26 to 0.44) |
| Takagaki et al.235 2016 | Targeted | University | Behavioural therapy vs. no intervention | Post intervention: 0.05 (0.02 to 0.08) |
| Social functioning | ||||
| Spence et al.206 2003 | Universal | Secondary | CBT vs. usual curriculum | Post intervention: 0.22 (–0.70 to 1.14) |
| Ryff Scales of Psychological Well-being | ||||
| Tomba et al.143 2010 | Universal | Secondary | CBT vs. CBT | Multiple subscales reported: autonomy, environmental mastery, personal growth, positive relations, purpose in life and self-acceptance |
Self-reported suicidal ideation, behaviour and self-harm
Author-defined suicidal ideation, behaviour or self-harm was referenced in 34 studies narratively or quantitatively. However, of these, the majority (n = 21) excluded participants reporting suicidal thoughts or behaviours and/or removed questions asking about suicide and self-harm from the baseline questionnaires. Some studies reported that the removal of questions was requested by participating schools or education authorities. Eleven studies reported that suicidal thoughts and behaviours were measured at baseline and that participants were referred to further services when necessary. However, nine did not then provide details on whether or not these students continued in the study, nor did they provide follow-up measures. The full details of these studies are reported in Appendix 7.
Seven studies reported participants experiencing suicidal thoughts or self-harm at post intervention.123,136,142,162,221,235,240 Details are reported in Table 11. Three studies were conducted in a universal secondary setting and formed a connected network via attention control. However, NMA model fit was suggestive of inconsistency, and combined results are not reported. Two studies were conducted in a targeted secondary setting, one in an indicated tertiary setting and one in a universal primary setting. There was no evidence to suggest that educational setting-based interventions to prevent anxiety and/or depression had an impact on suicidal ideation or thoughts of self-harm for CYP.
| Study | Analysis (population, setting) | Comparison | Outcome | Results |
|---|---|---|---|---|
| Perry et al.136 2017 | Universal, secondary | Attention control vs. CBT | Suicidal ideation | OR 0.83 (95% CrI 0.28 to 2.40) |
| aStallard et al.142 2013 | Universal, secondary | Attention control vs. usual curriculum | Self-harm thoughts | OR 0.87 (95% CrI 0.72 to 1.04) |
| Attention control vs. CBT + IPT | OR 0.83 (95% CrI 0.70 to 1.00) | |||
| Britton et al.123 2014 | Universal, secondary | Attention control vs. mindfulness/relaxation | Suicidal ideation or self-harm | Not estimable |
| Poppelaars et al.221 2016 | Indicated, secondary | Waiting list vs. CBT | Suicidal ideation | OR 2.20 (95% CrI 0.29 to 65.56) |
| Cova et al.162 2011 | Indicated, secondary | No intervention vs. CBT | Self-harm | Results not presented because of missing SDs |
| Roberts et al.240 2018 | Universal, primary | Usual curriculum vs. CBT vs. CBT | Suicidal ideation | For suicidal ideation, there was no significant group time interaction [F(2,198) = 2.84, p = 0.061]. There were, however, significant main effects for group [F(2,198) = 3.41, p = 0.035] and time [F(1,198) = 6.14, p = 0.014] |
| Takagaki et al.235 2016 | Indicated, tertiary/university | No intervention vs. behavioural activation | Suicidal ideation | OR 0.39 (95% CrI 0.05 to 2.28) |
Inequalities in health
None of the included studies reported the impact of the intervention on inequalities in health;241 therefore, we conducted post hoc subgroup analyses on the basis of available data. Data had been extracted on participant characteristics, including SES, sex and ethnicity (see Chapter 2). Descriptions of SES, sex and ethnicity, as defined by study authors, are reported in Appendix 7. Owing to insufficient data, subgroup analyses could not be conducted by sex or ethnicity for any population or setting. Subgroup analyses for studies conducted in lower socioeconomic settings (as described by the author) are reported.
Eleven studies reported being conducted in lower SES settings, of which three were conducted in MICs118,122,189 and eight in HICs.139,140,152,156,157,196,208,210 Interventions evaluated in lower SES settings were CBT relative to usual curriculum, no intervention or a waiting list. Unfortunately, for the primary time point of post intervention, data were available for only seven studies conducted in HICs.139,140,152,156,157,196,208 The results suggest that, in the case of interventions in secondary school settings, those delivered in lower SES settings may be less effective than those delivered in higher/mixed SES settings in reducing self-reported symptoms of anxiety. However, owing to the number of studies available, it was necessary to conduct fixed-effects analyses for the lower SES subgroup. This was not observed for self-reported depression, although it is of interest that the SMD for CBT compared with usual curriculum in higher/mixed SES settings was –0.07 (95% CrI –0.20 to 0.06); in lower SES settings, the SMD was 0.04 (95% CrI –0.06 to 0.15).
Table 12 reports the subgroup analysis findings. There was no evidence of a difference by SES for either self-reported depression or anxiety in primary educational settings. However, for self-reported anxiety, the SMD of CBT compared with usual curriculum in higher/mixed SES settings was 0.15 (95% CrI –0.37 to 0.02); in lower SES settings, the SMD was 0.05 (95% CrI –0.08 to 0.18).
| Population/setting | Outcome | Comparison | SES, SMD (95% CrI) | |
|---|---|---|---|---|
| Low | High/mixed | |||
| Universal secondary | Depression | CBT vs. usual curriculum | 0.04 (–0.06 to 0.15)a | –0.07 (–0.20 to 0.06) |
| Anxiety | CBT vs. usual curriculum | 0.09 (–0.11 to 0.29)a | –0.29 (–0.50 to –0.07) | |
| Universal primary | Depression | CBT vs. usual curriculum | –0.23 (–0.60 to 1.13) | –0.05 (–0.55 to 0.45) |
| Anxiety | CBT vs. usual curriculum | 0.05 (–0.08 to 0.18)a | –0.15 (–0.37 to 0.02) | |
Combined depression and anxiety scores and other ‘internalising’ outcomes
As described in Chapter 1, Changes to protocol, clarifications and additional analyses, and Table 1, a post hoc decision was made to assess composite ‘internalising’ outcomes, for example outcome scales that reported combined anxiety and depression scores (such as total Depression, Anxiety and Stress Scale or RCADS scores) or ‘internalising’ subscales of broader psychological functioning measures such as the SDQ. Six studies reported an internalising outcome, with useable data at post intervention, and are reported in Table 13 by population and setting.119,123,163,171,216,219 Four studies in targeted secondary settings provided sufficient data for inclusion in a random-effects NMA.163,171,216,219 Model fit statistics suggested that a consistency model was reasonable; however, the posterior median between-study SD was indicative of substantial heterogeneity (τ 0.97, 95% CrI 0.03 to 9.03) and tended to the prior distribution [uniform(0,10)]. Consequently, we report only study-specific SMDs in Table 13.
| Study | Population | Setting | Time | Comparison | Results, SMD (95% CrI) |
|---|---|---|---|---|---|
| Britton et al.123 2014 | Universal | Secondary | Post intervention | Attention control vs. mindfulness/relaxation | 0.12 (–0.32 to 0.54) |
| Aune and Stiles119 2009 | Universal | Secondary | Post intervention | No intervention vs. CBT | –0.02 (–0.10 to 0.06) |
| Fung et al.216 2016 | Targeted | Secondary | Post intervention | Waiting list vs. mindfulness/relaxation | –0.19 (–0.83 to 0.44) |
| McCarty et al.219 2013 | Targeted | Secondary | Post intervention | Psychosupport vs. CBT | –0.33 (–0.62 to –0.05) |
| Rice171 2009 | Targeted | Secondary | Post intervention | Attention control vs. CBT | 0.08 (–0.89 to 1.04) |
| Rice171 2009 | Targeted | Secondary | Post intervention | Attention control vs. mindfulness/relaxation | 0.41 (–0.31 to 1.13) |
| Dobson et al.163 2010 | Targeted | Secondary | Post intervention | Attention control vs. CBT | 0.19 (–0.26 to 0.64) |
A fixed-effects NMA was possible for a further two studies142,206 reporting a 12-month follow-up in a universal secondary setting, as they formed a connected network via usual curriculum.. However, there was no evidence that interventions based on CBT (SMD 0.03, 95% CrI –0.14 to 0.20) or CBT + IPT (SMD 0.01, 95% CrI –0.16 to 0.17) were more effective than usual curriculum for improving composite internalising outcomes at a 12-month follow-up.
Secondary outcomes
Acceptability and attendance
Intervention acceptability was defined by study authors. We anticipated considerable variability in the reporting of acceptability outcomes, but have combined them here under loose categories relating to (1) attitudes towards and satisfaction with intervention, (2) enjoyment and utility, and (3) attendance. Thirty-three studies reported a summary of acceptability of the intervention to study participants in terms of satisfaction or enjoyment and are summarised in Tables 14 and 15 by population and setting. Attendance data, as reported by authors, are reported in Appendix 7, Table 72.
| Study | Satisfaction |
|---|---|
| Baker and Butler120 1984 | This was measured using the Attitudes Toward Treatment Scale, a 14-item Likert-type scale, with possible scores ranging from 14 to 98. Higher scores indicate a higher degree of satisfaction. Treatment group: mean score 75.47 (SD 12.93); control group: mean score 63.69 (SD 10.02) |
| Potek137 2012 | On a 10-point Likert scale, the intervention group gave an average rating of 8.05 (SD 0.99, minimum 5.93, maximum 9.57). Higher scores indicate a higher degree of satisfaction |
| Fung et al.216 2016 | On a scale of 1–10, the author reports ‘moderate levels of satisfaction’ among participants (mean score 7.21, SD 0.67) |
| Kiselica et al.168 1994 | . . . female participants had a more favourable attitude toward training experience than did male participants, regardless of the treatment condition they were assigned to |
| McCarty et al.218 2011 | Participants were asked how satisfied they were with group membership: ‘very much’, 48%; ‘pretty much’, 36%; and ‘all right’, 13%. One student disliked the group ‘a little’ and felt ‘embarrassed’ (3%) |
| McCarty et al.219 2013 | Satisfaction: 83% liked their intervention group ‘very much’ or ‘pretty much’. Comfort: 84% of students were comfortable in their intervention group |
| Stice et al.224 2008 | In the two group-based interventions, 76% and 71% of respondents were ‘pleased’ or ‘very pleased’ with their assigned group. In the bibliotherapy group, 29% reported being ‘pleased’ or ‘very pleased’ |
| Higgins185 2007 | On a scale of 1–5, the mean satisfaction score was 4.0 (SD 0.47). The author describes this as showing that most participants were ‘somewhat satisfied’ with the workshop |
| Study | Enjoyment and usefulness of intervention |
|---|---|
| Stallard et al.142 2013 | Usual PSHE was preferred over both classroom-based CBT and attention control PSHE: liking (F 7.11, df 2970; p < 0.01), usefulness (F 6.46, df 2966; p < 0.01), relevance (F 8.84, df 2963; p < 0.01) |
| Merry et al.197 2004 | Enjoyment and usefulness were assessed using five-point Likert scales. Enjoyment: both the RAP-Kiwi intervention (mean score 3.0, SD 1.1) and attention control (mean score 3.7, SD 1.0) were rated ‘reasonably enjoyable’. Usefulness: RAP-Kiwi mean score 2.9 (SD 1.1); attention control mean score 3.1 (SD 1.1). Higher values indicate greater enjoyment and usefulness |
| Johnson et al.133 2017 | On a 10-point Likert scale, enjoyment and interest were rated as follows: mean score 6.92 (median 7.0, range 0–10). Higher values indicate greater enjoyment |
| Tak et al.207 2016 | Rated on a four-point Likert-scale. Authors report that participants did not like the intervention (mean score 1.58, SD 0.69) and did not find it useful (mean score 1.96, SD 0.85). Higher values indicate greater enjoyment and usefulness |
| Roberts et al.139 2010 | SLS: the ‘Learning to negotiate’ lessons were rated most enjoyable by students and ‘Networks’ the least enjoyable. Role plays were the most popular activities. A total of 68.7% to 79.0% rated the utility of SLS as average or higher |
| OTS: the most enjoyable activities were games and quizzes. A total of 67.3% rated the utility of OTS as average or higher | |
| Lowry-Webster et al.135 2001 | Participants were asked ‘How much did you enjoy the FRIENDS program?’; 31.1% enjoyed it ‘a lot’, 53.7% enjoyed it ‘some’, 14.2% ‘a little’ and 1% ‘not at all’ |
| Johnson et al.132 2016 | On a 10-point Likert scale, student enjoyment and interest was rated as follows: mean score 6.67 (median 7.0, range 0–10). Higher values indicate greater enjoyment and interest |
| Spence et al.206 2003 | A total of 42% would recommend the course to other students, 31% would maybe recommend it and 27% would not recommend the course. A total of 34% expected to use the skills learnt, 49% thought that they would maybe use the skills, and 17% did not think that they would use the skills in their everyday life |
| Rivet-Duval et al.202 2011 | Intervention participants rated the usefulness and acceptability of the programme as high (mean score 4.57, SD 0.78). (No detail provided on scale) |
| Britton et al.123 2014 | A total of 82% of students felt more focused, more able to concentrate or less distracted, and 88% reported feeling more relaxed and calmer |
| Calear et al.127 2016 | Over 60% of participants found the website to be useful or very useful . . . over 50% . . . reported they would use the website again and a further 10% had already recommended the website to a friend |
| Poppelaars et al.221 2016 | On a five-point scale, the mean response for liking OVK was 3.13 (SD 1.09); for SPARX, it was 3.16 (SD 1.35). The mean response for programme usefulness in daily life was 3.07 (SD 1.19) for OVK and 2.72 (SD 1.26) for SPARX |
| Cova et al.162 2011 | A total of 71.6% strongly agreed or agreed that participation was enjoyable, and 8.7% strongly disagreed or disagreed. A total of 79.0% strongly agreed or agreed that the intervention was useful, and 13.5% strongly disagreed or disagreed |
| Livheim et al.217 2015 | A total of 91% of participants ‘gave exclusively positive feedback’ about the intervention. Half stated that it was ‘very valuable’ and the remainder that it was ‘quite valuable’. All would recommend the course to a friend |
| Woods and Jose227 2011 | Participants reported the following positive aspects of the intervention: confectionery rewards, missing lessons and playing games. Negative aspects: amount of reading and writing required and ‘out-of-date’ scenarios |
| Ahlen et al.145 2018 | A total of 80% of participants in the high level of supervision group, compared with 68% in the low level of supervision group, enjoyed Friends for Life ‘much or some’ |
| Mendelson et al.210 2010 | The authors conducted focus groups:. . . students generally had a positive experience in the program and felt they learned skills that helped them in their day-to-day lives |
| Pophillat et al.156 2016 | The proportion of children who enjoyed the intervention was 92% |
| Soffer212 2003 | A total of 100% of participants in the behavioural intervention and 79% in the attention control group responded that they ‘would like to be in a program like this again’ |
| Attwood et al.146 2012 | Participants were generally positive about ‘Think, Feel, Do’ and no sessions were identified as unhelpful Most reported applying the skills learnt in their daily life. However, the authors note that content was challenging for some younger participants |
| Stallard et al.159 2014 | A total of 934 participants in the active arm responded that the intervention was fun, 742 thought that it had helped them and 787 would recommend the intervention to a friend |
| Essau et al.150 2012 | The authors state that children were asked whether or not they enjoyed the programme and if they used the skills taught. However, no results are reported |
| Ruttledge et al.158 2016 | A total of 68% of respondents found FRIENDS for Life ‘very useful’ or ‘somewhat useful’ |
| Schoneveld et al.116 2018 | On a five-point scale, participants were asked to rate (1) ‘I found it fun to participate in the intervention’ [CBT: mean score 2.35 (SD 1.39); biofeedback: mean score 2.77 (SD 1.18)] and (2) ‘I can use what I learned in my daily life well’ [CBT: mean score 2.96 (SD 0.95); biofeedback: mean score 2.13 (SD 1.38)] |
| Schoneveld et al.115 2016 | On a five-point scale, participants were asked to rate (1) ‘I liked to play the game’ [control: mean score 2.74 (SD 1.24); biofeedback: mean score 1.90 (SD 1.38); p ≤ 0.001) and (2) ‘I can use what I learned in my daily life well’ [control: mean score 1.72 (SD 1.28); biofeedback: mean score 1.68 (SD 1.29)] |
Attitudes and satisfaction with intervention
Eight studies reported satisfaction with the intervention (see Table 14). Two studies120,137 reported an overall satisfaction outcome in a universal secondary setting. Both used Likert-type scales and suggested that students were highly satisfied with the interventions. In targeted secondary settings, five studies reported a satisfaction or attitude to ‘treatment’ measure.168,216,218,219,224 However, results were reported for the experimental/active intervention arms only, and not for controls. All reported that participants were satisfied with their intervention assignment. One study185 in a targeted tertiary setting reported satisfaction with intervention assignment, with a mean score of 4.0 (SD 0.47) on a five-point scale, suggesting that the majority of participants were satisfied with the intervention.
Intervention enjoyment and utility
Twenty-five studies reported enjoyment or utility of intervention. In universal secondary settings, 11 studies reported an acceptability outcome assessing enjoyment or usefulness of the intervention.123,127,132,133,135,139,142,197,202,206,207 However, only two studies reported comparative data for all arms of the study. Stallard et al.142 note that the control group intervention: ‘Usual PSHE [personal, social and health education] was rated more positively than both classroom-based CBT and attention control PSHE for liking [F 7.11, df (degrees of freedom) 2970; p < 0.01], usefulness (F 6.46, df 2966; p < 0.01) and relevance for their age (F 8.84, df 2963; p < 0.01).’ Merry et al.197 compared intervention arms on a five-point Likert scale, where five was the most positive score and one the most negative. The programmes were rated by the students as reasonably enjoyable. The control group intervention received slightly higher ratings than the experimental intervention for both enjoyment and utility (see Table 15). The majority of studies reported that participants enjoyed the intervention and found it useful. Only one study reported negative enjoyment and utility feedback from students207 (see Table 15).
In universal primary settings, eight studies reported some detail for enjoyment or usefulness of the intervention.145,146,150,156,158,159,210,212 Two studies evaluating the FRIENDS anxiety programme reported an acceptability outcome assessing enjoyment or usefulness.158,159 In Ruttledge et al.,158 68% of the children found the FRIENDS for Life programme ‘very useful’ or ‘somewhat useful’. Stallard et al.159 reported that 74% of participants enjoyed the intervention, 59% thought that it had been helpful and 62% would recommend it to a friend. Across all studies, results suggest that participants generally found the interventions enjoyable and useful (see Table 15).
Four studies reported enjoyment/utility in targeted secondary settings.162,217,221,227 Poppelaars et al.221 provided comparative data for two CBT-based interventions and concluded that acceptability was similar across the programmes. Woods and Jose227 conducted semistructured focus groups at the end of a CBT intervention, Adolescents Coping with Emotions. The focus groups were conducted in New Zealand, with the majority of participants being Maori and Pacific Islander students and identifying trust in the group as an important benefit of the intervention. In addition, some participants noted that the insight gained about thinking processes was useful. Participants liked the use of confectionery as a reward, and identified the games played and missing class as good aspects of the programme. However, they also felt that the intervention used out-of-date scenarios and that there was too much reading and writing involved in the sessions. Livheim et al.217 reported that most participants (91%) gave exclusively positive feedback on the evaluation of the acceptance and commitment therapy-based intervention and all reported that they would recommend it to a friend. The majority of students included in Cova et al.’s162 study enjoyed (71.6%) and found the CBT intervention useful (79%).
Two studies provided information on enjoyment in a targeted primary setting.115,116 Schoneveld et al.116 noted that children enjoyed both the experimental and control interventions equally (CBT vs. biofeedback). However, in an earlier trial, in which the control intervention was a commercially available computer game, children clearly preferred the control intervention.115
Attendance and dropouts from intervention
Only one study explicitly mentioned attendance as a proxy for acceptability of the intervention to participants. Congleton215 noted that attendance was excellent and that this reflected how much the students enjoyed the course and the importance of convenient timetabling.
Across all other studies, attendance was reported descriptively. Study-specific attendance details, as reported by trial author, are reported in Appendix 7.
Parent-reported child anxiety, depression or internalising outcomes
A post hoc decision was made to analyse parent-reported child anxiety, depression or internalising symptoms. For some of the studies, participants were considered too young for self-reported measures and parents were the primary respondents. In universal primary settings, five studies145,146,156,158,242 provided baseline and follow-up data on parent-reported child anxiety outcomes. From a random-effects NMA, there was no evidence that CBT-based interventions reduced parent-reported child anxiety symptoms relative to usual curriculum (SMD –0.10, 95% CrI –2.13 to 1.83).
Six studies115,116,176,177,181,182 provided both baseline and follow-up data to enable a NMA for targeted primary settings. There was no evidence that CBT-based interventions (SMD –0.43, 95% CrI –1.08 to 0.14), biofeedback (SMD –0.48, 95% CrI –1.76 to 0.72) or occupational therapy (SMD 0.05, 95% CrI –1.07 to 1.19) reduced parent-reported child anxiety symptoms relative to a waiting list.
Academic attainment
Seven studies reported academic attainment data.131,136,137,145,159,168,174 Various measures of attainment were used; we report study-specific results in Table 16. Across all studies, there was no evidence of an effect of intervention on academic outcomes.
| Study | Measure | Results, mean difference (95% CI) |
|---|---|---|
| Ahlen et al.145 2018 | Teacher-rated five-point scale | 0.01 (–0.10 to 0.12) |
| Cooley-Strickland et al.174 2011 | WIAT-reading (age equivalent) | 0.30 (–0.24 to 0.83) |
| Cooley-Strickland et al.174 2011 | WIAT-mathematics (age equivalent) | 0.30 (–0.20 to 0.80) |
| Hodas131 2016 | Mathematics computation (age equivalent) | Results reflect an older age of students in a waiting list group |
| Hodas131 2016 | Reading comprehension | Results reflect an older age of students in a waiting list group |
| Kiselica et al.168 1994 | Quarterly GPA | Univariate F tests revealed [no] significant differences between the treatment and control participants for GPA |
| Perry et al.136 2017 | Final exam results (standardised) | Notably, academic outcomes did not differ between the 2 groups p = 0.41 |
| Potek137 2012 | SAT language assessment | –0.10 (–1.60 to 1.40) |
| aStallard et al.159 2014 | SAT reading | 0.10b (–0.56 to 0.76) |
| aStallard et al.159 2014 | SAT mathematics | 1.83b (1.13 to 2.53) |
| aStallard et al.159 2014 | SAT writing | 0.68b (0.02 to 1.34) |
| aStallard et al.159 2014 | SAT reading | 0.93b (0.30 to 1.57) |
| aStallard et al.159 2014 | SAT mathematics | 1.15b (0.45 to 1.85) |
| aStallard et al.159 2014 | SAT writing | 1.48b (0.84 to 2.12) |
Problem behaviours
Few studies reported problem behaviours, and those that did reported substance use. The following results are reported as per the original publications. In a universal secondary setting, Stallard et al.142 reported that there was evidence of a beneficial effect of CBT + IPT on cannabis use at 6 months (OR 0.56, 95% CI 0.38 to 0.82) and at 12 months (OR 0.70, 95% CI 0.48 to 0.93), but not on alcohol or ‘street drug’ use. In targeted secondary settings, Stice et al.224 reported that CBT reduced ‘substance use’ (F[6,674] 3.60; p = 0.002) relative to control and Topper et al.173 reported that there was ‘no significant difference’ between the intervention and control groups for binge drinking (Cohen’s d 0.22). In a tertiary/university setting, Reynolds et al.233 reported results from the Alcohol Use Disorders Identification Test (AUDIT) and concluded that there was ‘no significant difference’ observed between the intervention and control groups for alcohol consumption or alcohol problems, although they also report that:
. . . a significant interaction of the orientation group effect with the linear effect of time was found, suggesting differential change for the [intervention] and [control] groups across the three time points. The overall percentage of youth above the clinical cut off for the BATD [behavioural activation treatment for depression] group generally decreased over time.
Mental health-related stigma
During our initial PPI work, reducing the stigma associated with mental health problems was identified as an important outcome for young people. Only one study reported a mental health-related stigma outcome. In Perry et al.,136 stigma was measured using a nine-item subscale of the Depression Stigma Scale, an 18-item scale that assesses personal and perceived stigma towards depression, on which higher scores indicate greater stigma. At the immediate post-intervention time point, there was no evidence of a reduction in personal or perceived stigma in the SPARX (smart, positive, active, realistic, X-factor thoughts) computerised CBT group, compared with the attention control intervention (mean difference –0.50, 95% CI –2.90 to 1.90).