Mental health interventions in schools in high-income countries

The right place at the right time

Background:The vast majority of children and adolescents in low and middle-income countries (LMICs) lack access to interventions for mental health problems. Schools provide a critical platform for evidence-based intervention delivery for young people. However, a significant need exists to understand the implementation context and strategies for delivering school mental health interventions in LMICs.Methods:We conducted a focused ethnography to explore students’, teachers’, and caregivers’ perspectives on implementing evidence-based mental health interventions (EBIs) within a widespread violence prevention program in Uganda. Data collection occurred in Kampala, Uganda, using two schools that have previously implemented an evidence-based violence prevention program widely used in Ugandan schools schools, the Good School Toolkit (GST). Trained, local researchers facilitated four focus group discussions (FGDs) with caregivers (n = 22), four FGDs with teachers (n = 25), and in-depth interviews with primary school students (n = 12). Verbatim transcripts were analyzed using a framework analysis approach.Results:Participants revealed a school culture that promotes schools’ responsibility to students beyond academics, including positive teacher–student relationships. Participants recommended an implementation process that trains teachers and students in screening and referral, peer group delivery, and is accompanied by a school-wide approach to stigma reduction and mental health literacy. Participants fundamentally agreed that teachers could be trained as intervention facilitators.Conclusions:This study highlights the potential advantage of leveraging an existing intervention that already addresses implementation factors, such as school culture, as a fertile platform for implementing interventions for child and adolescent mental health in LMICs.Plain language abstract:Despite the growth of implementation research for child and adolescent mental health, the study of implementation science for child and adolescent mental health in low and middle-income countries (LMICs) remains scarce. Schools provide a critical platform for evidence-based intervention delivery for young people. However, a significant need exists to understand the implementation context and strategies for delivering school mental health interventions in LMICs. This study provides rich qualitative data describing the context and influences for the successful implementation of mental health interventions in LMIC schools. We conducted interviews and focus groups with teachers, students, and caregivers to determine their perspectives on implementing evidence-based mental health interventions (EBIs) within a widespread violence prevention program in Uganda. Participants revealed a school culture promoted by the existing program that promotes schools’ responsibility to students beyond academics, including positive teacher–student relationships. Findings suggest the existing program provides fertile ground for the successful implementation of evidence-based mental health interventions in schools.

Mental health interventions in schools

Mental health interventions in schools in low-income and middle-income countries

Child mental health is a growing concern for policymakers across the global north. Schools have become a key site for mental health interventions, with new programmes aimed at promoting ‘resilience’, through which children may maintain or regain mental health during adversity. As one of the first studies to explore the early impact of intensive mental health promotion in schools from children’s perspectives, we adopt a governmentality approach to consider the logic and techniques of such programmes with a specific focus on England. An innovative visual methodology was used to focus on student perspectives of mental health interventions in school. Young peoples’ photo representations of mental health were collected and used to stimulate focus group discussions with 65 students aged 12–14, across seven schools. ‘Resilience’ was seen to be the key organising concept for mental health interventions in schools. The concept was viewed as narrowly focused on attitude towards—and performance in—school work, with individuals being encouraged to ‘push on through’ difficulties to achieve success. Young people were critical of this approach, suggesting several alternatives. These included increased access to independent mental health professionals, safe spaces within schools and mental health education that addressed the social and affective dimensions of mental health difficulties.

Preventative interventions may be effective in reducing and preventing symptoms of mental ill health in children and young people. However, there is a paucity of research in this area that explores the views of young people. This paper reports on a qualitative study to inform the future development of attractive and appropriate early and preventative school-based mental health interventions. Semi-structured interviews were conducted with a purposive sample of 12 young people aged 14-17 in North East England. Interviews were audio-recorded, transcribed, anonymised and analysed following a thematic approach. Four key themes were identified, relevant to those providing, designing and commissioning early and preventative mental health interventions in schools: 'mental health literacy', 'risk factors for wellbeing decline', 'experience of school-based support' and 'recommendations for future support'. Young people have varying levels of mental health literacy, but are able to identify academic stress, bullying and the transition from primary to secondary school as leading causes of worry. Young people want more regular and in-depth mental health education, tailored levels of support in school and improved training for teachers.

BackgroundAssessment of mental health in schools has garnered increased interest in recent years. Children spend a large proportion of their waking hours in schools. Teachers can act as gatekeepers by playing a key role in identifying children with mental health difficulties in the classroom and making the necessary onward referrals to external services. The prevalence of mental health difficulties, their impact on schooling (and beyond) and the importance of early intervention means that it is incumbent on schools to identify and support potentially affected children.AimsPrevious reviews focused on mental health interventions in schools; however, this review focuses on the assessment of mental health in schools and on teachers' perceptions of this, as such a review is still lacking. Therefore, the study fills a gap in the existing literature while also providing new, highly relevant evidence that may inform policy making in this area.Composition of studies included in this reviewThis review included 19 studies. Five studied teachers exclusively at primary/elementary level, and seven focused on secondary level, while six included both primary and secondary teachers. Three studies employed mixed methods, ten were primarily qualitative studies, and five were primarily quantitative.MethodsBronfenbrenner's (The ecology of human development: Experiments by nature and design, Harvard University Press, 1979) framework, adapted by Harvest (How can EPs best support secondary school staff to work effectively with children and young people who experience social, emotional and mental health difficulties? 2018), which includes the mature version of the theory (Tudge et al., 2009, J. Fam. Theory Rev., 1, 198), was used to analyse the literature.ResultsResults found that lack of training in assessment of mental health and ‘role conflict’ were key barriers; some teachers attributed this to their lack of knowledge, skills and confidence in the area.ConclusionImplications for practice and research are discussed in relation to the importance of sustained training both pre‐service and in‐service.

Mental health interventions in schools are essential for supporting adolescents with neurodevelopmental disorders (NDDs). Schools offer a unique setting for early intervention due to their accessibility and continuity, promoting regular monitoring and engagement. This review explores a multi-tiered mental health framework that includes universal, targeted, and intensive strategies such as social-emotional learning (SEL), cognitive-behavioral therapy (CBT), peer-support programs, and culturally responsive practices. Evidence suggests that these interventions improve mental health outcomes, enhancing academic performance, social skills, and resilience. SEL programs build competencies like emotional regulation, while CBT reduces symptoms of anxiety, depression, and behavioral issues. Peer-support initiatives offer accessible support, reducing stigma within the school community. For students with NDDs, specialized interventions such as social skills training and applied behavior analysis (ABA) demonstrate positive impacts on social functioning and school engagement. The review also examines implementation barriers, including limited resources and the lack of culturally adaptable approaches. Teacher training and community involvement emerge as vital for bridging gaps in mental health support. Advocacy for policy and funding is essential to sustain these programs, ensuring they meet the diverse needs of all students. Through an inclusive, collaborative approach, school-based interventions significantly contribute to adolescent development and well-being.

There are a number of challenges and debates surrounding the implementation of mental health interventions in schools. These include recognising the complexity of influencing factors and the interdependency of key components; the critical importance of monitoring school-based implementation in particular contexts; employing multimethod evaluation designs that can capture the complexity; and judging success using mental health and educational outcomes. These factors are shaped by both mental health and educational research. The prevention paradox focusing on the whole population ‘prevents’ more illness than targeting programs to specific individuals, and is exemplified in school mental health promotion that utilises an ecological or whole school approach. MindMatters, an innovative Australian mental health promotion and pr evention program, illustrates the challenges in this new field of endeavour. Its design and implementation are consistent with recommended effective practice, a comprehensive program that targets multiple health outcomes in the context of a coordinated whole school approach (Jané-Lopis, Barry, Hosman, & Patel, 2005). MindMatters moves beyond the sole focus on the curriculum to acknowledge the key roles of teacher professional development and whole school change within a strengths-based approach. As recommended by Jané-Lopis et al. (2005) measures of key school mental health outcomes are being used, ranging from absenteeism and drop-out rates to the development of social skills and academic achievement. The MindMatters evaluation suite of five separate yet interrelated evaluation studies illustrates some of the complexity involved.

Schools are well positioned to provide access to youth mental health services, but implementing effective programs that promote emotional and behavioral functioning in school settings is complicated by the poor fit of interventions developed in research settings to complex school contexts. The current study formed a research-practice partnership with two urban public schools and mental health providers employed by those schools (N = 6, 100% female, 50% Black/African American, 50% White/Caucasian) in the adaptation of a depression prevention intervention, Act & Adapt. The intervention was modified by decreasing meeting time and streamlining session content, increasing flexibility, making intervention materials more similar to academic curriculum, and increasing the focus on managing disruptive behavior within group sessions. In an open trial, 6th grade students (N = 22; 59% boys, 31% Hispanic, 22% Black/African American, 4% Asian, 30% White/Caucasian) at both schools who were identified as clinically "at risk" reported improvements from baseline to post-intervention and at one-year follow-up on measures of emotional and behavioral difficulties and coping strategies, with parallel results by caregiver report. The providers reported satisfaction with the intervention, and qualitative analyses of provider focus groups suggested both barriers and facilitators to research-practice collaborations to implement mental health interventions in schools.

Recent societal crises have negatively impacted the mental health of adolescents, emphasizing the need for effective preventative mental health interventions. Schools as key environments for young people offer opportunities to deliver those interventions at low threshold. However, many interventions are not sustained beyond initial funding periods due to persistent implementation barriers, contributing to a significant gap between intervention development and long-term practice. This systematic review synthesizes qualitative research on barriers and facilitators affecting the implementation of school-based interventions in secondary schools in high-income countries. Seven databases were searched for qualitative and mixed-methods studies on the implementation of preventative school-based mental health interventions in regular secondary schools. Implementation determinants were synthesized using the updated version of the Consolidated Framework for Implementation Research. Study quality was assessed using modified checklists of the Critical Appraisal Skills Programme. Twenty-six studies, involving 5 to 8,630 pupils, met the inclusion criteria. A total of 336 implementation factors were identified, with barriers (N = 207; 61.6%) outweighing facilitators (N = 129; 38.4%). Barriers included scheduling conflicts, low prioritization of mental health, and logistical challenges. Key facilitators were leadership support, age-appropriate intervention design, and staff engagement. Sustained success of preventative mental health interventions requires integrating programs into school structures, aligning with academic priorities, and addressing resource limitations. Future research should focus on adapting interventions to fit school contexts and strengthening leadership and community support. Understanding multidimensional, interacting implementation factors is essential for creating sustainable interventions that positively impact adolescent mental health.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00787-025-02796-5.

AWARE (Approaches for Wellbeing and Mental Health Literacy: Research in Education) is a three-arm, parallel-group, cluster randomised controlled trial. It assessed the effectiveness of two interventions - the Youth Aware of Mental Health (YAM) programme and Mental Health and High School Curriculum Guide - in addressing emotional well-being, compared with usual practice, among year 9 students in England. To evaluate the cost-effectiveness of YAM and The Guide to inform policy decisions regarding the implementation of these mental health interventions in schools. Cost-effectiveness was assessed using self-reported information from participants in the trial at baseline and two follow-ups - at 3-6 months after the start of intervention, and at 9-12 months post-intervention. Quality of life was measured with the Child Health Utility Index. Intervention delivery costs were calculated with data provided by the delivery teams. Service use costs were calculated with a short version of the Client Service Receipt Inventory, with unit costs obtained from publicly available sources. For both interventions, difference in outcomes (change in quality-adjusted life-years over time) between the intervention group and control group were close to zero, with the largest change being an improvement of 0.0055 quality-adjusted life-years at the second follow-up for students in schools randomised to YAM. Changes in costs were likewise small. At first follow-up, neither intervention is likely to be considered cost-effective. At second follow-up, YAM has a high probability of being considered cost-effective, with an incremental cost-effectiveness ratio of around £23 000 per unit of improvement in the quality-of-life measure, which falls within the threshold (£20 000 to £30 000) as used by the National Institute for Health and Care Excellence.

Schools have been identified as an ideal setting for increasing access to mental health services particularly for underserved minority youth. The emerging field of implementation science has begun to systematically investigate strategies for more efficiently integrating evidence-based practices into community settings. Significantly less translational research has focused specifically on the school setting. To address this need, we examined the implementation of a school-based trauma intervention across three distinct regions. We conducted key informant interviews guided by Mendel's Framework of Dissemination in Health Services Intervention Research with multiple school stakeholders to examine what school organizational characteristics influence the adoption and implementation process and sustainability of Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Participants were selected from schools in three geographic regions in the United States: Western, Midwestern, and Southern. Our findings reveal that while sites had some common organizational factors that appeared to facilitate implementation, regions differed in how they compensated for less robust implementation domains. Across all regions, school stakeholders recognized the need for services to support students impacted by trauma. In the Western region, there was no centralized district policy for implementation; therefore, implementation was facilitated by school-level change agents and supervision support from the district mental health unit. In the Midwestern region, centralized district policies drove implementation. In both the Midwestern and Southern regions, implementation was facilitated by collaboration with a local mental health agency. This study contributes to the paucity of empirical information on the organizational factors that influence the implementation of evidence-based mental health interventions in schools. Our findings reveal that different implementation strategies across policies, structures, and resources can result in implementation of a school-based intervention. Frameworks such as Mendel's can be helpful in identifying areas of strength and improvement of implementation within a school organization.

There are a number of terms that can be confusing when schools are involved n planning to meet students mental health needs. We see terms such as empirically supported, research-based, evidence-based, proven, well-established, promising, efficacious, and probably efficacious (Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald, 2001; Lembke & Stormont, 2005). These terms are not equivalent and it is important to distinguish between them. An understanding of the term evidence-based is particularly important as it can be misunderstood and misused.

Purpose – The purpose of this paper is to examine students’ understandings of mental health and their learning preferences, in order to provide guidance for developing targeted mental health education. Design/methodology/approach – A study-specific self-administered questionnaire was used at two English schools (n=980; ages 11-18), incorporating a combination of open-ended and fixed-choice items. Data were subject to content analysis, cross-tabulation of frequencies and statistical analyses. Findings – Overall, students understood mental health in terms of personal attributes or disorder, however older students were more likely to talk about relationships. Males were less likely to say they wanted to learn about mental health than females, believing they had no need to learn more. White students were also less interested in learning about mental health than Indian students. Overall, students said they would not use social media to learn, however Indian students were most likely to want to use it. Younger students preferred school-based learning to online. Research limitations/implications – The questionnaires were study specific and self-report. However interesting demographic variations in responses were found, worthy of further exploration. Social implications – Policymakers should consider targeted mental health interventions in schools and research the potential roles/barriers of the internet and social media. Long-term possible benefits relate to improved preventative strategies within schools. Originality/value – Previous research has focused on the delivery of mental health promotion/education in schools, whereas the current study drew on a large sample of students to understand how they define mental health for themselves, as well as how they prefer to learn about it.