Psychological Medicine A systematic review of effectiveness and

cambridge.org/psm
cost-effectiveness of school-based
identification of children and young people
at risk of, or currently experiencing mental
Review Article health difficulties
Cite this article: Anderson JK et al (2018). A
systematic review of effectiveness and
cost-effectiveness of school-based Joanna K. Anderson1, Tamsin Ford2, Emma Soneson3, Jo Thompson Coon2,
identification of children and young people at
risk of, or currently experiencing mental health Ayla Humphrey3, Morwenna Rogers2, Darren Moore4, Peter B. Jones3,
difficulties. Psychological Medicine 49, 9–19. Emmet Clarke5 and Emma Howarth1
https://doi.org/10.1017/S0033291718002490
1
Received: 13 March 2018 NIHR CLAHRC East of England, University of Cambridge, Institute of Public Health, Douglas House, 18
Revised: 31 July 2018 Trumpington Road, Cambridge CB2 8AH, UK; 2University of Exeter Medical School, South Cloisters, St Luke’s
Accepted: 13 August 2018 Campus, Exeter EX1 2LU, UK; 3Department of Psychiatry, University of Cambridge, Herschel Smith Building, Forvie
First published online: 13 September 2018 Site, Robinson Way, Cambridge CB2 0SZ, UK; 4Graduate School of Education, St Luke’s Campus, Exeter EX1 2LU,
UK and 5Norfolk and Suffolk NHS Foundation Trust, 80 St Stephens Rd, Norwich NR1 3RE, UK
Key words:
mental health; mental wellbeing; schools;
identification; screening; children; young Abstract
people; students; education Background. Although school-based programmes for the identification of children and young
Author for correspondence: people (CYP) with mental health difficulties (MHD) have the potential to improve short- and
Joanna K. Anderson, E-mail: jpa44@medschl. long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness
cam.ac.uk of these programmes is underdeveloped. In this systematic review, we sought to identify and
synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to
identify students experiencing MHD, as measured by accurate identification, referral rates,
and service uptake.
Method. Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British
Education Index and ASSIA were searched. Comparative studies were included if they assessed
the effectiveness or cost-effectiveness of strategies to identify students in formal education
aged 3–18 years with MHD, presenting symptoms of mental ill health, or exposed to psycho-
social risks that increase the likelihood of developing a MHD.
Results. We identified 27 studies describing 44 unique identification programmes. Only one
study was a randomised controlled trial. Most studies evaluated the utility of universal screen-
ing programmes; where comparison of identification rates was made, the comparator test var-
ied across studies. The heterogeneity of studies, the absence of randomised studies and poor
outcome reporting make for a weak evidence-base that only generate tentative conclusions
about the effectiveness of school-based identification programmes.
Conclusions. Well-designed pragmatic trials that include the evaluation of cost-effectiveness
and detailed process evaluations are necessary to establish the accuracy of different identifica-
tion models, as well as their effectiveness in connecting students to appropriate support in
real-world settings.

Background
In the UK, one in 10 children and young people (CYP) aged 5–16 years suffers from a psy-
chiatric disorder; many more experience symptoms that, whilst not reaching the threshold
of clinical disorder, cause significant distress for CYP and their families (Green et al.,
2005). Failure to address mental health difficulties (MHD) early in life affects individuals’
long-term functioning and wellbeing, and may also generate significant societal costs related
to increased health care usage, unemployment, and antisocial behaviours (Joint
Commissioning Panel for Mental Health, 2013).
Less than 35% of CYP with diagnosable MHD are identified (Burns et al., 1995), and only
25% of those with clinically impairing psychiatric disorder receive specialist care (Ford et al.,
2007). A small number of studies suggest that parents of CYP with MHD often do not realise
that their child may benefit from specialist support (Girio-Herrera et al., 2013). Formal iden-
© Cambridge University Press 2018 tification can highlight the severity of the child’s MHD, and encourage parents to seek profes-
sional help. Well-designed programmes to identify CYP with MHD show promise for
increasing access to supportive services, and may improve mental health (MH) outcomes if
combined with evidence-based interventions (D’Souza et al., 2005; Sayal et al., 2010; Husky
et al., 2011; Mitchell et al., 2012).

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 10 Joanna K. Anderson et al.

There is strong international policy consensus that schools are Since the paper describes studies that evaluated the accuracy of
well positioned to play a significant role in the early identification identification of suicide risk, it is important to note there is a con-
of CYP at risk of mental illness. Systematic school-based sensus that, although identification of suicide risk yields a high
approaches detect a greater proportion of CYP with MHD com- number of false positive results, the harm of these inaccurate
pared with less formal processes (i.e. ah-hoc teacher or parent identifications is outweighed by the benefit of prevention for
identification, or self-identification) (Garland, 1995; Eklund future suicides among those whose risk is correctly identified
et al., 2009; Scott et al., 2009; Dowdy et al., 2013; Kieling et al., (Carter et al., 2017). The result of recent systematic review showed
2014). Students identified in school settings are more likely to that pooled positive predictive value of clinical instruments used
receive parental and school support, as well as referral and access to assess suicide risk is around 5.5%, which suggests that majority
to MH services (D’Souza et al., 2005; Nemeroff et al., 2008; Sayal of individuals who screen positive will, in fact, not attempt suicide
et al., 2010; Lyon et al., 2015), and to achieve better long-term (Carter et al., 2017).
MH outcomes, compared with students with MHD identified in
community healthcare settings (Ford et al., 2008; Husky et al.,
Inclusion and exclusion criteria
2011; Mitchell et al., 2012). However, teachers do not feel well
equipped to perform this role and consistently under-identify Comparative studies were included if they assessed the effective-
early symptoms of various disorders (Caldarella et al., 2008; ness or cost-effectiveness of strategies to identify students in for-
Bruhn et al., 2014; Cunningham and Suldo, 2014). mal education aged 3–18 years (1) with a MHD, (2) presenting
The evidence-base on programmes to improve identification of symptoms of mental ill health, or (3) exposed to psychosocial
MHD in school settings has not been synthesised. In this paper, risks that increase the likelihood of developing a MHD.
we sought to synthesise evidence on the effectiveness and cost- Studies that focused on the identification of global and specific
effectiveness of school-based methods to identify CYP at risk of learning disabilities were excluded.
or experiencing MHD. This is a part of a larger systematic review We included studies published in any year comparing the
of the effectiveness, harms, feasibility, and acceptability of school- effectiveness of different identification models within the same
based methods to identify CYP with MHD; findings on harms, group, and studies in which the accuracy of identification was
feasibility, and acceptability will be published separately in due verified by a subsequent clinical evaluation, or compared with
course. Given that we were specifically interested in the utility existing MH diagnoses.
of the identification mechanism, effectiveness was defined as (i)
rate of accurate identification (i.e. correct identification of cases)
Search strategy
of CYP with MHD; (ii) rate of referrals to appropriate supportive
services following identification; (iii) uptake of referrals to sup- Electronic bibliographic databases: MEDLINE and Embase via
portive services. Cost-effectiveness was defined broadly as the out- OvidSP; PsycINFO, ERIC, and British Education Index via
come of analysis comparing the resources required to deliver an EBSCOhost; and ASSIA via ProQuest were searched in May and
intervention with the health, quality of life or other assumed out- June 2017 and again in July 2018. The search strategy combined
comes achieved by an intervention (Knapp and Iemmi, 2013). terms for identification and school settings with terms for MH.
Search terms were generated by examining the terminology
used in key publications in the field, identifying synonyms, and
Methods
discussing with experts in school-based MH research. The search
The protocol was registered with the International Prospective terms were combined with standard MeSH terms for the
Register of Systematic Reviews (PROSPERO; https://www.crd. MEDLINE database, Emtree terms for Embase, Thesaurus
york.ac.uk/prospero), registration number: 42016053084 terms for ERIC, British Education Index and ASSIA, and
(amended version dated 18 January 2017). Subject Headings for the PsycINFO database. Supplementary
search methods included forward and backward citation search,
and hand-searching CYP MH journals. The MEDLINE search
School-based methods of identification
strategy is shown in an online Supplementary Table S1.
The literature describes four main models of school-based identi-
fication of MHD (Whitney et al., 2011). Universal screening pro-
Selection of studies
grams aim to systematically assess all students for risks of MHD
using self-, parent-, or teacher-report measures (Whitney et al., Two independent reviewers selected studies in three stages: (1) all
2011). Curriculum-based models, delivered to all students in a titles were examined to remove obviously irrelevant reports; (2)
year group by a staff member or external person with relevant abstracts of remaining studies were examined against inclusion/
knowledge, are designed to increase students’ knowledge and rec- exclusion criteria; (3) full-texts of remaining reports were exam-
ognition of common MH problems, and develop skills to address ined for compliance with inclusion/exclusion criteria. We resolved
them. (Whitney et al., 2011). Staff in-service models rely on train- disagreements by referral to another research team member.
ing all members of staff to recognise early signs of MHD and link
students deemed to be at-risk with appropriate support. (Whitney
Data extraction
et al., 2011). Teacher nomination involves asking a class teacher to
identify students in their classroom who exhibit concerning beha- The fields of the extraction tables were piloted and refined using
viours or symptoms that may indicate the presence of MHD three randomly selected studies included in the review. Two
(Cunningham and Suldo, 2014). Additionally, we included trad- researchers independently extracted data from included studies.
itional identification methods using office disciplinary referrals We extracted the following information: first author, year of pub-
(ODRs), grade point average, attendance data, and teacher referral lication, and country where the study was conducted, study
to identify students at risk of MHD. design, study aims, school level, informants, identification

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 Psychological Medicine 11

measures, description of an identification programme, character- Rates of accurate identification

istic of a sample, and findings. In a separate table, we listed pro-
grammes’ components (online Supplementary Table S4). Results Findings from all studies are described in an online
were compared and disagreements were resolved by referral to Supplementary Table S3. Section ‘Universal screening pro-
another research team member. grammes’ describes studies that evaluated the effectiveness of a
single identification model (universal screening programmes);
subsequent sections describe studies that compared the effective-
Study appraisal
ness of universal screening and other identification models.
We appraised the quality of included studies with the Effective (1) Universal screening programmes
Public Health Practice Project (EPHPP) Quality Assessment Eight studies of universal screening programmes reported on
Tool for Quantitative Studies (Armijo‐Olivo et al., 2012), which rates of identification (Tisher, 1995; Jones et al., 2002; Gould
has been deemed suitable to use systematic reviews of effective- et al., 2009; Robinson et al., 2010; Husky et al., 2011; Morey
ness (Deeks et al., 2003). The tool includes six quality compo- et al., 2015; Hilt et al., 2018). In six studies, positive screening
nents: selection bias, study design, confounders, blinding, data results were verified by subsequent clinical interview conducted
collection and drop-out rated against set criteria as strong, mod- by MH professionals (Gould et al., 2009; Robinson et al., 2010;
erate, or weak. Two researchers independently conducted quality Husky et al., 2011; Morey et al., 2015; Hilt et al., 2018), or an
appraisal judging each study against criteria listed for each quality existing diagnosis of MHD (Tisher, 1995), giving a reliable rate
component; results were compared and disagreements were of false positives.
resolved by referral to another team member. Depression and anxiety: Studies that utilised student-report
screening measures and subsequent clinical interview, found
that 45–63% of secondary school students were identified as
Synthesis of results
being at high-risk for depression (Robinson et al., 2010; Morey
Due to high heterogeneity of study designs, interventions, and et al., 2015). Teacher-completed universal screening accurately
outcome measures, it was not appropriate to conduct a meta- distinguished between students with and without clinical depres-
analysis. We provided a numerical account of evidence and sion diagnoses; students currently treated for depression scored
narrative synthesis of evidence-guided by the framework for sys- significantly higher compared with their non-diagnosed counter-
tematic reviews developed by Popay et al. (2006). This framework parts ( p < 0.0001) (Tisher, 1995).
comprises four iterative stages: developing the theory of change, Behavioural and socioemotional problems: One study consid-
preliminarily synthesising of findings, exploring relationships in ered the utility of teacher- and parent-completed universal screen-
the data, and assessing the robustness of syntheses. We described ing by the examination of long-term outcomes for children
findings separately for each research questions, as well as an over- identified in kindergarten as at high-risk of behavioural and
all summary and conclusions (Popay et al., 2006). socioemotional problems (Jones et al., 2002). Children identified
as high-risk were significantly more likely, in the next 6 years, to
receive professional outpatient and inpatient MH services ( p <
Findings
0.05), take medication for MH reasons ( p < 0.01), and receive spe-
Twenty-seven studies were included in the final review Fig. 1 out- cial education services or MH-related school counselling ( p <
lines the study selection process. 0.01), compared with low-risk children (Jones et al., 2002).
Characteristics of included studies are shown in Table 1. Risk of suicide: Student-report universal screening identified
Studies covered a total of 44 unique identification programmes. 317 students out of 2342 screened (13%) as being at risk of sui-
Publication dates suggest increasing interest in this area over cide. Subsequent clinical interview, however, indicated that 43%
the last two decades, but it should be noted that nearly all evi- of these outcomes were false positives, (Gould et al., 2009),
dence comes from the USA. Nearly half of the studies were cross- which indicates over-identification as we anticipated. In contrast,
sectional (n = 13), followed by comparison group (n = 8) and following completion of a universal screening measure, all stu-
cohort analytic studies (n = 4). There was only one case-control dents in two other studies, regardless of risk-status, participated
study and one randomised controlled trial (RCT). Most focussed in a brief interview with a school counsellor. Interview outcomes
on secondary school settings (n = 16) and identification of behav- indicated that screening yielded around 20% false negative results,
ioural and emotional problems. Nine studies evaluated universal which suggests that this method is likely to miss a significant
screening models; remaining studies compared universal screen- number of students needing support (Husky et al., 2011; Hilt
ing with teacher nomination (n = 12), traditional identification et al., 2018).
methods (n = 3) and staff in-service training (n = 1). One cost- (2) Universal screening programmes v. teacher nomination
effectiveness study compared universal screening, staff in-service Twelve studies compared identification rates from universal
training, and curriculum-based models. Detailed characteristics screening and school staff nomination models (Tisher, 1995;
of studies are presented in an online Supplementary Table S2. Auger, 2000; 2004; Campbell, 2004; Dwyer et al., 2006; Eklund
et al., 2009; Scott et al., 2009; Dowdy et al., 2013; Cunningham
and Suldo, 2014; Kieling et al., 2014; Sweeney et al., 2015;
Quality of included studies
Kilgus et al., 2018). In four studies positive identification out-
As shown in Table 2, nearly a quarter of included studies were comes were verified by subsequent clinical interview (Auger,
rated weak on selection bias, lacking sufficient description of 2000; 2004; Scott et al., 2009; Kieling et al., 2014; Sweeney
recruitment procedures and representativeness of the sample. et al., 2015), while remaining studies reported rates of overlap
Nearly half of the studies failed to report withdrawals and attri- in identification between screening and staff nomination.
tion. All but one study was rated strong for data collection, having Depression and anxiety: Findings from a study that employed a
utilised standardised and validated measures. multi-stage model of universal screening and a clinical interview

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 12 Joanna K. Anderson et al.

Fig. 1. Study selection and exclusion flow diagram.

to identify students with depression showed that this method pro- positive and negative results for each method cannot be deter-
duced a high number of false-positive results (up to 90%). By mined (Campbell, 2004; Cunningham and Suldo, 2014).
comparison, teacher nomination yielded a false positive rate of Behavioural and socioemotional problems: Seven studies com-
nearly 70% (Auger, 2000; 2004). Universal screening for social pared identification rates of students with behavioural and socio-
anxiety disorder (SAD) yielded fewer false-positives(20%), with emotional problems that used universal screening and
only 12% of subsequently diagnosed students identified by tea- nomination models (Tyne and Flynn, 1981; Garland, 1995;
chers (Sweeney et al., 2015); seven students with a final SAD diag- Dwyer et al., 2006; Eklund et al., 2009; Dowdy et al., 2013;
nosis were identified solely by teacher nomination. Other Kieling et al., 2014; Kilgus et al., 2018). Only one study verified
evidence suggests that teachers correctly nominate 41–68% of stu- positive results of screening with subsequent clinical evaluation
dents who screen positive for depression and/or anxiety, but since (Kieling et al., 2014); remaining studies reported rates of overlaps
tested models did not include a clinical interview, the rates of false between model outcomes. Evidence suggests that student-report

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 Psychological Medicine 13

Table 1. Characteristics of included studies Table 1. (Continued.)

No of No of
studies studies
Criterion Characteristic (n total = 27) Criterion Characteristic (n total = 27)

Year Before 1990 1 No 0

1991–2000 5 ND 37
2001–2010 9 Referral/ Yes 9
recommendations
After 2010 12 No 1
following identificationa
Country USA 21 ND 32
Ireland 2 ND, not defined
a
In total 44 identification programmes are described in 24 studies. Some studies describe
Australia 3 more than one programme thus some characteristics are reported multiple times for one
study
Brazil 1 b
Some studies are conducted in multiple schools, at different school levels
Study design RCT 1
Case-control 1
universal screening identifies at least twice as many at-risk stu-
Comparison group 8 dents as teacher nomination (Garland, 1995; Eklund et al.,
Cohort analytic 4 2009; Dowdy et al., 2013). Teachers identify 10–30% of students
Cross-sectional 13
identified by a universal screener (Garland, 1995; Dwyer et al.,
2006; Eklund et al., 2009; Dowdy et al., 2013). They are more
Identification modela Universal screening 26 likely to nominate students who have more severe difficulties
Teacher/ school staff 11 (Garland, 1995), and more ODRs (Dowdy et al., 2013).
nomination However, combining universal screening and nomination did
Traditional school 5 not increase the accuracy of identification compared with univer-
identification sal screening alone (Kilgus et al., 2018). One study found that a
Curriculum-based 1
parent-completed universal screener more accurately identified
students subsequently diagnosed with internalising disorders,
In-service training 2 compared with a teacher-completed measure (30–46% and 26–
Informants a
Student 16 34%, respectively). In contrast, teachers’ positive global judgement
Teacher/other school 17
about children’s risk of developing MHD better predicts future
staff externalising problems, compared with parent’s judgement
(Dwyer et al., 2006). Findings from another study suggest the
Parent 4
agreement between results of peer-report universal screening
Condition Depression and anxiety 7 and teacher nomination increases with students’ age from 19%
Behavioural and 12 in 3rd grade (7–8 years old) to 55% in 5th grade (10–11 years
socioemotional old) (Tyne and Flynn, 1981), perhaps because older students
problems can more accurately judge others’ behaviours.
Risk of suicide 6 ADHD: Only one study focussed on the identification of chil-
dren with ADHD. Identification results were verified by the full
Substance abuse 1
clinical assessment that suggested very low levels of agreement
b
School level Preschool 3 between teacher-completed screening and simple nomination
Primary school 11 ( p < 0.0002) (Kieling et al., 2014). Seventeen out of 18 children
with clinically-confirmed ADHD diagnoses were identified by at
Secondary school 16
least one screening measure (Kieling et al., 2014), while the agree-
a
Parent consent Yes 30 ment between nomination and the final diagnosis was signifi-
No 0 cantly higher for negative cases than positive cases.
Risk of suicide: One study compared the results of student-
ND 12
report universal screening for suicide risk and school staff nomin-
a
Student assent Yes 12 ation, with outcomes verified by subsequent clinical interview
No 0 (Scott et al., 2009). MH professionals correctly nominated twice
as many students as did administrative staff, with an accurate
ND 30
nomination rate of 36%, whereas screening correctly identified
Follow-up clinical Yes 16 63% of at-risk students. Screening yielded a 9% false-positive
evaluationa rate compared with 24% produced by staff nomination. Both
No 29
methods combined produced only 5% false positives.
ND 9
(3) Universal screening programmes v. traditional school iden-
Informing students/ Yes 5 tification methods
parents about resultsa Three studies compared the accuracy of universal screening
(Continued ) and traditional identification methods used by schools (i.e.

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 14 Joanna K. Anderson et al.

Table 2. Quality of included studies – EPHPP tool

Selection Study Data

1st author (year); study design bias design Confounders Blinding collection Drop out

Rates of accurate identification

Universal screening
Depression and anxiety
Morey (2015); comparison group weak weak NA NA strong strong
Robinson (2010); cohort analytic weak moderate NA NA strong moderate
Tisher (1995); case-control moderate moderate NA NA strong strong
Behavioural and socioemotional problems
Forness (1998); comparison group moderate moderate NA NA strong weak
Jones (2002); cohort analytic moderate moderate NA NA strong strong
Risk of suicide
Gould (2009); cohort analytic moderate moderate NA NA strong moderate
Hilt (2018); cross-sectional Moderate Weak NA NA Strong weak
Husky (2011); RCT moderate strong strong moderate strong strong
Universal Screening v. Nomination
Depression and anxiety
Auger (2000, 2004); cross-sectional weak weak NA NA strong weak
Cunningham (2014); cross-sectional weak weak NA NA strong weak
Sweeney (2015); cross-sectional strong weak NA NA strong strong
Campbell (2004); comparison group moderate weak NA NA strong weak
Behavioural and socioemotional problems
Dowdy (2013); cross-sectional moderate weak NA NA weak strong
Dwyer (2006); cohort analytic moderate moderate NA NA strong weak
Eklund (2009); comparison group moderate weak NA NA strong weak
Garland (1995); cross-sectional moderate weak NA NA strong moderate
Kieling (2014); comparison group moderate weak NA NA strong strong
Kilgus (2018) cross-sectional moderate weak NA NA strong moderate
Tyne (1981); cross-sectional weak weak NA NA strong weak
Risk of suicide
Scott (2009); cross sectional moderate weak NA NA strong moderate
1st author (year); study design Selection bias Study design Confounders Blinding Data collection Drop out
Universal screening v. traditional identification methods
Behavioural and socioemotional problems
Eklund (2014); cross Sectional moderate weak NA NA strong weak
Hallfors (2006); Comparison group moderate moderate NA NA strong weak
Naser (2014); Cross-sectional moderate weak NA NA weak moderate
Universal screening v. staff in-service training
Substance abuse
McLaughlin (1993); Comparison group moderate weak NA NA strong strong
Rates of referral and uptake
Cotter (2015); Comparison group moderate weak NA NA strong weak
Also see: Gould (2009), Hilt (2018), Husky (2011)
Cost-effectiveness
Burke (2013); cross-sectional weak weak NA NA strong weak

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 Psychological Medicine 15

ODRs, grade point average, attendance data, and teacher referral) currently in treatment. The majority (89%) were referred to com-
(Hallfors et al., 2006; Eklund and Dowdy, 2014; Naser, 2014). munity services, and those remaining received referrals to school
Neither study verified outcomes by clinical assessment, reporting services. Case-management confirmed that 50.2% of referred stu-
only rates of overlaps between methods. dents attended one or more appointments; 22.5% completed three
Behavioural and socioemotional problems: Traditional identifi- or more appointments.
cation based on teacher-referral and academic performance iden- Of the 2488 students included in the Husky et al. (2011) study,
tified less than 40% of children who screened positive for universal screening and subsequent clinical interview identified
internalising or externalising disorders (Eklund and Dowdy, 299 (12%) students as at-risk of suicide (Husky et al., 2011).
2014). Of kindergarten children identified by teacher-completed Based on current suicidal ideation as assessed by clinical inter-
universal screening as being high-risk, less than 40% were identi- view, past suicide attempts, and current MH treatment status,
fied by traditional methods during the first year of primary school 128 (43% of those identified) students received a referral to
(Forness et al., 1998). However, a substantial number of children school-based MH services only, 78 (26%) to community-based
identified by schools’ normal procedures were assigned to a differ- MH services only, and 93 (31%) to both school and community-
ent diagnostic category than the one indicated by the results of based services. Of those referred, 76% had at least one appoint-
screening using validated, standardised measures (Forness et al., ment with a MH provider and 56% received minimally adequate
1998). treatment defined as three or more appointments or any number
Substance abuse: A study that compared the outcomes of uni- if terminated by provider’s recommendation. Among the 221 stu-
versal screening and traditional methods of identifying substance- dents referred to school-based services, 80% attended at least one
abusing students based on student’s GPA, attendance record, and appointment, 71.3% of whom received minimally adequate treat-
teacher referrals yielded equivocal results (Hallfors et al., 2006). In ment. Of 171 students referred to community-based services, 42%
one sample of students, high-risk of substance abuse indicated by received at least one visit, 68% of whom received minimally
student-report screening was associated with low GPA, while in adequate treatment.
other sample, low attendance and teacher referral, but not GPA, Another study reported the uptake of a clinical interview fol-
were strong predictors of substance abuse. lowing a positive student-report screen for suicide risk (Cotter
(4) Universal screening programmes v. staff in-service programmes et al., 2015). Of 516 students invited for a follow-up assessment,
Substance abuse: Results of one study suggest that attending 37% attended. Recent suicide attempt, high levels of depressive,
in-service training improves teachers’ ability to correctly nomin- anxiety or emotional symptoms, hyperactivity/inattention, peer
ate students identified by student-report universal screening as relationship problems, and functional impairment increased the
being at-risk of substance abuse (McLaughlin et al., 1993). likelihood of attending a follow-up interview.
Teachers who completed the training more accurately identified
students who were experimenting with, and regularly using
drugs and alcohol, compared with their colleagues who had not Cost-effectiveness
attended the training, thereby reducing the gap in identification Only one study compared the cost-effectiveness of different meth-
rates between the two methods ( p < 0.001). ods of identifying suicide risk (Burke et al., 2013), and concluded
that universal screening is more cost-effective (in terms of
Rates of referrals and service uptake improving quality-adjusted life years – i.e. function of quality
and length of life), than curriculum-based or in-service training
Although a number of studies indicated that a referral was made programmes. The study utilised data from a sample of 11 100 ado-
for students identified as being at-risk, only three studies reported lescents from 168 schools across 10 European Union countries, so
numbers and uptake of referrals to specialist support (Gould although the findings may accurately represent average cost-
et al., 2009; Husky et al., 2011; Hilt et al., 2018). All three studies effectiveness of suicide screening across the EU countries, results
evaluated universal screening for risk of suicide, although referral may differ by country and world region. This represents a gap in
processes and services offered varied by programme. Of 317 stu- the research literature.
dents identified as at-risk of suicide by student-report screening in
the Gould et al. (2009) study, 182 (57%) were deemed to require
additional support following a second clinical stage interview Discussion
(Gould et al., 2009). Referrals were made for 147 students (of
Summary of findings
whom 29 were already receiving MH services) reporting severe
suicidality; the remaining 35 were given a list of local providers We identified 27 studies with a total of 26 256 participants that
without a specific referral. The uptake of follow-up recommenda- analysed the effectiveness of school-based MHD identification
tions was 70.3%. Uptake did not differ between students who programmes. None of the studies was UK-based. Only one
received a specialist referral or list of providers; those who were study used a randomised design. Most studies evaluated the utility
not currently receiving services were significantly more likely to of universal screening but programmes differed in format and
follow-up with the referral compared with those already in treat- outcomes; where comparison of identification rates was made,
ment. Overall, 24% of the new service users had their first the comparator test varied across studies. Whilst the purported
appointment within a month of the screening. Within 6 months, aim of many programmes was to increase the rate of MH support
52% attended their first appointment, and within a year, 70% had among children and young people, only two studies reported
successfully accessed a MH care provider (Gould et al., 2009). Of referral and uptake data.
2022 students participating in a universal screening for suicide Overall, the heterogeneity of studies, the absence of rando-
risk programme, 444 students were determined to be in need of mised studies and poor outcome reporting make for a weak
MH services following screening and clinical interview (Hilt evidence-base that only generate tentative conclusions about the
et al., 2018). Of those identified as being at-risk, 77% were not effectiveness of school-based identification programmes.

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 16 Joanna K. Anderson et al.

Summary of effects of interventions the role of programme components in the causal pathway leading
to benefit, no effect or harm. We also note that there was poor
Some evidence suggests that overall, universal screening may be
attention to broader contextual factors that may influence pro-
the most effective method of identification; however, the rate of
gramme implementation and outcomes, Intervention develop-
false-positive results yielded by this method is high (Auger,
ment, modelling, feasibility and pilot studies, along with trials
2000; 2004; Husky et al., 2011), so the expectations of teachers,
of effectiveness, need to theorise and evaluate the contextual con-
pupils, and parents would need to be managed accordingly.
ditions necessary for intervention mechanisms to be activated. If
Some findings indicate that multistage models are more accurate
there is to be any hope of identifying and scaling promising pro-
(Scott et al., 2009; Morey et al., 2015; Sweeney et al., 2015); how-
grammes, then concerted effort is needed to articulate, test and
ever two studies reported that a single assessment with a universal
refine programme theories underpinning these complex interven-
screening measure is sufficient to accurately identify high-risk
tions so as to make explicit how individual study components and
individuals, and additional assessments and informants do not
contextual factors interact to generate desired outcomes (Wells
improve accuracy (Dowdy et al., 2016; Kilgus et al., 2018).
et al., 2012; Fletcher et al., 2016; Howarth et al., 2016).
Teacher nomination yields a higher number of false negative
Commissioners and practitioners call for more interventions to
results than universal screening (Campbell, 2004; Dwyer et al.,
be tested real-life settings, since the focus on internal validity and
2006; Eklund et al., 2009; Dowdy et al., 2013; Cunningham and
creating optimal conditions can significantly limit external rele-
Suldo, 2014). Teachers are most likely to nominate high-risk stu-
vance and impede dissemination (Bowen et al., 2009). More eco-
dents, while those who are at-risk but without obvious signs of
nomic evaluations of identification programmes are required to
MHD are often overlooked in ad-hoc identification procedures
inform the resource allocation to achieve the best value for money.
(Ollendick et al., 1990; Auger, 2004). Limited evidence suggests
that staff in-service training and curriculum-based programmes
improve identification of MHD (McLaughlin et al., 1993;
Robinson et al., 2010); however, costs associated with programme Quality of the evidence
delivery make them less feasible than universal screening (Burke More than half of included studies were rated weak in terms of
et al., 2013). Combining universal screening and staff nomination study design, and documentation of withdrawals and drop-outs.
shows promise for increasing accuracy of identification (Gould Only one RCTs was identified, despite recommendations for trials
et al., 2009; Scott et al., 2009), although this proposition requires that focus on both outcomes and processes (Oakley et al., 2006).
testing using randomised designs. Nearly a quarter had not sufficiently described sample selection
Few studies focused on identification of pre- and primary and recruitment procedures, which raises questions about the
school children. It is vital to identify children with MHD as generalisability of results. Most included studies compared out-
early as possible since evidence shows that presence MHD in chil- comes of two different identification models in the same sample
dren as young as three years old can impact future outcomes of students. Authors draw conclusions about models’ accuracy
across multiple domains including education, employment, sub- based on overlaps between their results, thereby assuming that
stance use, criminal activity, and physical and MH (Jones et al., if students are identified by two independent models, then the
2015). Half of MHD is evident by the age of 14, with the even outcome is most likely correct. Few studies that verified outcomes
earlier onset of anxiety and impulse control disorders. There is, with subsequent clinical interview further assessed students ini-
therefore, a strong case for developing methods of identification tially identified as being at-risk, thereby failing to account for
for use in primary school settings (Jones, 2013). false negative results. Studies evaluating the effectiveness of iden-
Very few studies reported rates of service referral and uptake tification models need to include an established, reliable method
following identification. Given that MH services are already over- of verifying both positive and negative results, to minimise the
whelmed, commissioners, and service providers may be con- risk of harms that may result from the failure to identify children
cerned that school-based identification, and universal screening who have MHD, as well as the over-diagnosis of MHD among
programmes in particular (which yield a significant number of children without MH problems (Cohen et al., 2016).
false positive results), will add unwarranted pressure to already
struggling services. Conversely, evidence suggests some children
have subclinical levels of psychopathology and will benefit from
Strengths and limitations
specialist support (Ford T et al., 2005).
Few studies explicitly set out to assess adverse events or harms To our knowledge, this is the first attempt to synthesise evidence
associated with identification. Since it is recognised that the iden- for the effectiveness of school-based identification models. The
tification process may cause distress, especially in high-risk stu- inclusion criteria were designed to encompass all existing identi-
dents (Robinson et al., 2011), all studies should assess negative fication models. The broad scope in terms of study design offered
consequences associated with identification. a more comprehensive and realistic understanding of the state of
In general, the description of programmes was poor, with key school-based identification than if we excluded ad-hoc identifica-
details such as methods for obtaining consent omitted. Poor tion methods. Second, the review included all age groups, from
reporting of interventions is ubiquitous, and is in part explained pre-school to secondary school, which allowed for comparison
by the word limits imposed on authors for papers published in across school levels. Third, the review did not place any restriction
peer-reviewed journals (Hoffmann et al., 2014; Maggin and on the type of MH condition, which allowed for cross-condition
Johnson, 2015). Nevertheless, without adequate description, it is comparisons. Finally, in addition to exploring the effectiveness of
difficult, if not impossible, to compare trials. The mechanisms the different models, we also examined referral and uptake rates.
by which interventions were hypothesised to lead to change This is important because school-based identification models do
were also rarely reported. This, in combination with poor pro- not end at screening, and understanding the subsequent pathways
gramme description, means we were unable to identify and define to care is essential.

https://doi.org/10.1017/S0033291718002490 Published online by Cambridge University Press

 Psychological Medicine 17

Notwithstanding, we acknowledge several limitations. First, the scope of the review, particularly defining the search terms and specifying
review only included studies published in English. Second, while the inclusion/exclusion criteria, reviewed, and reviewed all manuscript
we generally view our broad inclusion criteria as positive, the lack versions. J. Thompson Coon and M. Rogers advised on methodology, particu-
larly the development of search strategy, inclusion/exclusion criteria, and data
of exclusion based on study design led to the inclusion of several
extraction, and reviewed all manuscript versions, with a particular focus on
methodologically weak studies. While we kept a broad scope in
methods. A. Humphrey reviewed all manuscript versions and contributed to
terms of MHD, we did not include neurodevelopmental condi- writing the discussion. D. Moore and P. Jones reviewed all manuscript
tions or learning disabilities, which may be closely linked to versions. E. Clarke, as a second reviewer, contributed to a screening of titles
MH problems. Finally, the quality and heterogeneity of included and abstracts. All authors read and approved the final version of the
studies precluded meta-analysis or any other statistical summary. manuscript.
Future reviewers may seek to broaden the aims of the present
review through the inclusion of these conditions. Acknowledgements. This paper presents independent research funded by
the National Institute for Health Research (NIHR) Collaboration for
Leadership in Applied Health Research & Care (CLAHRC) East of England,
Conclusions at Cambridgeshire and Peterborough NHS Foundation Trust, and CLAHRC
South West. The views expressed are those of the author(s) and not necessarily
This first comprehensive systematic review of the effectiveness of those of the NHS, the NIHR or the Department of Health and Social Care.
school-based models of identifying children at risk of, or experi-
encing MHD shows that the current evidence-base is very limited Conflict of interests. None
and does not support the recommendation of any particular
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