research paper related to the school health problems or issues

The Impact of School Mental Health on Student and School-Level Academic Outcomes: Current Status of the Research and Future Directions

Original Paper
Published: 20 December 2013
Volume 6 , pages 84–98, ( 2014 )

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research paper related to the school health problems or issues

Shannon M. Suldo 1 ,
Matthew J. Gormley 2 ,
George J. DuPaul 2 &
Dawn Anderson-Butcher 3

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This manuscript summarizes areas of school mental health (SMH) research relevant to the interplay between students’ academic and social–emotional outcomes. After advancing a multidimensional conceptualization of academic success at the levels of individual students and schools, we summarize observational and intervention studies that connect students’ mental health to their academic achievement, with acknowledgment of the bidirectional relationship. Then, current and future directions of SMH research are discussed, including (a) the impact of SMH health initiatives and services on schools’ achievement, (b) the need to address the mental health of historically neglected subgroups of students, and (c) interdisciplinary collaborations necessary to support enhanced outcomes. Based on the findings from these literature integrations, we conclude with recommendations and implications for research and practice.

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Suldo, S.M., Gormley, M.J., DuPaul, G.J. et al. The Impact of School Mental Health on Student and School-Level Academic Outcomes: Current Status of the Research and Future Directions. School Mental Health 6 , 84–98 (2014). https://doi.org/10.1007/s12310-013-9116-2

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Student mental health is in crisis. Campuses are rethinking their approach

Amid massive increases in demand for care, psychologists are helping colleges and universities embrace a broader culture of well-being and better equipping faculty to support students in need

Vol. 53 No. 7 Print version: page 60

Mental Health

college student looking distressed while clutching textbooks

By nearly every metric, student mental health is worsening. During the 2020–2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide ( Lipson, S. K., et al., Journal of Affective Disorders , Vol. 306, 2022 ). In another national survey, almost three quarters of students reported moderate or severe psychological distress ( National College Health Assessment , American College Health Association, 2021).

Even before the pandemic, schools were facing a surge in demand for care that far outpaced capacity, and it has become increasingly clear that the traditional counseling center model is ill-equipped to solve the problem.

“Counseling centers have seen extraordinary increases in demand over the past decade,” said Michael Gerard Mason, PhD, associate dean of African American Affairs at the University of Virginia (UVA) and a longtime college counselor. “[At UVA], our counseling staff has almost tripled in size, but even if we continue hiring, I don’t think we could ever staff our way out of this challenge.”

Some of the reasons for that increase are positive. Compared with past generations, more students on campus today have accessed mental health treatment before college, suggesting that higher education is now an option for a larger segment of society, said Micky Sharma, PsyD, who directs student life’s counseling and consultation service at The Ohio State University (OSU). Stigma around mental health issues also continues to drop, leading more people to seek help instead of suffering in silence.

But college students today are also juggling a dizzying array of challenges, from coursework, relationships, and adjustment to campus life to economic strain, social injustice, mass violence, and various forms of loss related to Covid -19.

As a result, school leaders are starting to think outside the box about how to help. Institutions across the country are embracing approaches such as group therapy, peer counseling, and telehealth. They’re also better equipping faculty and staff to spot—and support—students in distress, and rethinking how to respond when a crisis occurs. And many schools are finding ways to incorporate a broader culture of wellness into their policies, systems, and day-to-day campus life.

“This increase in demand has challenged institutions to think holistically and take a multifaceted approach to supporting students,” said Kevin Shollenberger, the vice provost for student health and well-being at Johns Hopkins University. “It really has to be everyone’s responsibility at the university to create a culture of well-being.”

Higher caseloads, creative solutions

The number of students seeking help at campus counseling centers increased almost 40% between 2009 and 2015 and continued to rise until the pandemic began, according to data from Penn State University’s Center for Collegiate Mental Health (CCMH), a research-practice network of more than 700 college and university counseling centers ( CCMH Annual Report , 2015 ).

That rising demand hasn’t been matched by a corresponding rise in funding, which has led to higher caseloads. Nationwide, the average annual caseload for a typical full-time college counselor is about 120 students, with some centers averaging more than 300 students per counselor ( CCMH Annual Report , 2021 ).

“We find that high-caseload centers tend to provide less care to students experiencing a wide range of problems, including those with safety concerns and critical issues—such as suicidality and trauma—that are often prioritized by institutions,” said psychologist Brett Scofield, PhD, executive director of CCMH.

To minimize students slipping through the cracks, schools are dedicating more resources to rapid access and assessment, where students can walk in for a same-day intake or single counseling session, rather than languishing on a waitlist for weeks or months. Following an evaluation, many schools employ a stepped-care model, where the students who are most in need receive the most intensive care.

Given the wide range of concerns students are facing, experts say this approach makes more sense than offering traditional therapy to everyone.

“Early on, it was just about more, more, more clinicians,” said counseling psychologist Carla McCowan, PhD, director of the counseling center at the University of Illinois at Urbana-Champaign. “In the past few years, more centers are thinking creatively about how to meet the demand. Not every student needs individual therapy, but many need opportunities to increase their resilience, build new skills, and connect with one another.”

Students who are struggling with academic demands, for instance, may benefit from workshops on stress, sleep, time management, and goal-setting. Those who are mourning the loss of a typical college experience because of the pandemic—or facing adjustment issues such as loneliness, low self-esteem, or interpersonal conflict—are good candidates for peer counseling. Meanwhile, students with more acute concerns, including disordered eating, trauma following a sexual assault, or depression, can still access one-on-one sessions with professional counselors.

As they move away from a sole reliance on individual therapy, schools are also working to shift the narrative about what mental health care on campus looks like. Scofield said it’s crucial to manage expectations among students and their families, ideally shortly after (or even before) enrollment. For example, most counseling centers won’t be able to offer unlimited weekly sessions throughout a student’s college career—and those who require that level of support will likely be better served with a referral to a community provider.

“We really want to encourage institutions to be transparent about the services they can realistically provide based on the current staffing levels at a counseling center,” Scofield said.

The first line of defense

Faculty may be hired to teach, but schools are also starting to rely on them as “first responders” who can help identify students in distress, said psychologist Hideko Sera, PsyD, director of the Office of Equity, Inclusion, and Belonging at Morehouse College, a historically Black men’s college in Atlanta. During the pandemic, that trend accelerated.

“Throughout the remote learning phase of the pandemic, faculty really became students’ main points of contact with the university,” said Bridgette Hard, PhD, an associate professor and director of undergraduate studies in psychology and neuroscience at Duke University. “It became more important than ever for faculty to be able to detect when a student might be struggling.”

Many felt ill-equipped to do so, though, with some wondering if it was even in their scope of practice to approach students about their mental health without specialized training, Mason said.

Schools are using several approaches to clarify expectations of faculty and give them tools to help. About 900 faculty and staff at the University of North Carolina have received training in Mental Health First Aid , which provides basic skills for supporting people with mental health and substance use issues. Other institutions are offering workshops and materials that teach faculty to “recognize, respond, and refer,” including Penn State’s Red Folder campaign .

Faculty are taught that a sudden change in behavior—including a drop in attendance, failure to submit assignments, or a disheveled appearance—may indicate that a student is struggling. Staff across campus, including athletic coaches and academic advisers, can also monitor students for signs of distress. (At Penn State, eating disorder referrals can even come from staff working in food service, said counseling psychologist Natalie Hernandez DePalma, PhD, senior director of the school’s counseling and psychological services.) Responding can be as simple as reaching out and asking if everything is going OK.

Referral options vary but may include directing a student to a wellness seminar or calling the counseling center to make an appointment, which can help students access services that they may be less likely to seek on their own, Hernandez DePalma said. Many schools also offer reporting systems, such as DukeReach at Duke University , that allow anyone on campus to express concern about a student if they are unsure how to respond. Trained care providers can then follow up with a welfare check or offer other forms of support.

“Faculty aren’t expected to be counselors, just to show a sense of care that they notice something might be going on, and to know where to refer students,” Shollenberger said.

At Johns Hopkins, he and his team have also worked with faculty on ways to discuss difficult world events during class after hearing from students that it felt jarring when major incidents such as George Floyd’s murder or the war in Ukraine went unacknowledged during class.

Many schools also support faculty by embedding counselors within academic units, where they are more visible to students and can develop cultural expertise (the needs of students studying engineering may differ somewhat from those in fine arts, for instance).

When it comes to course policy, even small changes can make a big difference for students, said Diana Brecher, PhD, a clinical psychologist and scholar-in-residence for positive psychology at Toronto Metropolitan University (TMU), formerly Ryerson University. For example, instructors might allow students a 7-day window to submit assignments, giving them agency to coordinate with other coursework and obligations. Setting deadlines in the late afternoon or early evening, as opposed to at midnight, can also help promote student wellness.

At Moraine Valley Community College (MVCC) near Chicago, Shelita Shaw, an assistant professor of communications, devised new class policies and assignments when she noticed students struggling with mental health and motivation. Those included mental health days, mindful journaling, and a trip with family and friends to a Chicago landmark, such as Millennium Park or Navy Pier—where many MVCC students had never been.

Faculty in the psychology department may have a unique opportunity to leverage insights from their own discipline to improve student well-being. Hard, who teaches introductory psychology at Duke, weaves in messages about how students can apply research insights on emotion regulation, learning and memory, and a positive “stress mindset” to their lives ( Crum, A. J., et al., Anxiety, Stress, & Coping , Vol. 30, No. 4, 2017 ).

Along with her colleague Deena Kara Shaffer, PhD, Brecher cocreated TMU’s Thriving in Action curriculum, which is delivered through a 10-week in-person workshop series and via a for-credit elective course. The material is also freely available for students to explore online . The for-credit course includes lectures on gratitude, attention, healthy habits, and other topics informed by psychological research that are intended to set students up for success in studying, relationships, and campus life.

“We try to embed a healthy approach to studying in the way we teach the class,” Brecher said. “For example, we shift activities every 20 minutes or so to help students sustain attention and stamina throughout the lesson.”

Creative approaches to support

Given the crucial role of social connection in maintaining and restoring mental health, many schools have invested in group therapy. Groups can help students work through challenges such as social anxiety, eating disorders, sexual assault, racial trauma, grief and loss, chronic illness, and more—with the support of professional counselors and peers. Some cater to specific populations, including those who tend to engage less with traditional counseling services. At Florida Gulf Coast University (FGCU), for example, the “Bold Eagles” support group welcomes men who are exploring their emotions and gender roles.

The widespread popularity of group therapy highlights the decrease in stigma around mental health services on college campuses, said Jon Brunner, PhD, the senior director of counseling and wellness services at FGCU. At smaller schools, creating peer support groups that feel anonymous may be more challenging, but providing clear guidelines about group participation, including confidentiality, can help put students at ease, Brunner said.

Less formal groups, sometimes called “counselor chats,” meet in public spaces around campus and can be especially helpful for reaching underserved groups—such as international students, first-generation college students, and students of color—who may be less likely to seek services at a counseling center. At Johns Hopkins, a thriving international student support group holds weekly meetings in a café next to the library. Counselors typically facilitate such meetings, often through partnerships with campus centers or groups that support specific populations, such as LGBTQ students or student athletes.

“It’s important for students to see counselors out and about, engaging with the campus community,” McCowan said. “Otherwise, you’re only seeing the students who are comfortable coming in the door.”

Peer counseling is another means of leveraging social connectedness to help students stay well. At UVA, Mason and his colleagues found that about 75% of students reached out to a peer first when they were in distress, while only about 11% contacted faculty, staff, or administrators.

“What we started to understand was that in many ways, the people who had the least capacity to provide a professional level of help were the ones most likely to provide it,” he said.

Project Rise , a peer counseling service created by and for Black students at UVA, was one antidote to this. Mason also helped launch a two-part course, “Hoos Helping Hoos,” (a nod to UVA’s unofficial nickname, the Wahoos) to train students across the university on empathy, mentoring, and active listening skills.

At Washington University in St. Louis, Uncle Joe’s Peer Counseling and Resource Center offers confidential one-on-one sessions, in person and over the phone, to help fellow students manage anxiety, depression, academic stress, and other campus-life issues. Their peer counselors each receive more than 100 hours of training, including everything from basic counseling skills to handling suicidality.

Uncle Joe’s codirectors, Colleen Avila and Ruchika Kamojjala, say the service is popular because it’s run by students and doesn’t require a long-term investment the way traditional psychotherapy does.

“We can form a connection, but it doesn’t have to feel like a commitment,” said Avila, a senior studying studio art and philosophy-neuroscience-psychology. “It’s completely anonymous, one time per issue, and it’s there whenever you feel like you need it.”

As part of the shift toward rapid access, many schools also offer “Let’s Talk” programs , which allow students to drop in for an informal one-on-one session with a counselor. Some also contract with telehealth platforms, such as WellTrack and SilverCloud, to ensure that services are available whenever students need them. A range of additional resources—including sleep seminars, stress management workshops, wellness coaching, and free subscriptions to Calm, Headspace, and other apps—are also becoming increasingly available to students.

Those approaches can address many student concerns, but institutions also need to be prepared to aid students during a mental health crisis, and some are rethinking how best to do so. Penn State offers a crisis line, available anytime, staffed with counselors ready to talk or deploy on an active rescue. Johns Hopkins is piloting a behavioral health crisis support program, similar to one used by the New York City Police Department, that dispatches trained crisis clinicians alongside public safety officers to conduct wellness checks.

A culture of wellness

With mental health resources no longer confined to the counseling center, schools need a way to connect students to a range of available services. At OSU, Sharma was part of a group of students, staff, and administrators who visited Apple Park in Cupertino, California, to develop the Ohio State: Wellness App .

Students can use the app to create their own “wellness plan” and access timely content, such as advice for managing stress during final exams. They can also connect with friends to share articles and set goals—for instance, challenging a friend to attend two yoga classes every week for a month. OSU’s apps had more than 240,000 users last year.

At Johns Hopkins, administrators are exploring how to adapt school policies and procedures to better support student wellness, Shollenberger said. For example, they adapted their leave policy—including how refunds, grades, and health insurance are handled—so that students can take time off with fewer barriers. The university also launched an educational campaign this fall to help international students navigate student health insurance plans after noticing below average use by that group.

Students are a key part of the effort to improve mental health care, including at the systemic level. At Morehouse College, Sera serves as the adviser for Chill , a student-led advocacy and allyship organization that includes members from Spelman College and Clark Atlanta University, two other HBCUs in the area. The group, which received training on federal advocacy from APA’s Advocacy Office earlier this year, aims to lobby public officials—including U.S. Senator Raphael Warnock, a Morehouse College alumnus—to increase mental health resources for students of color.

“This work is very aligned with the spirit of HBCUs, which are often the ones raising voices at the national level to advocate for the betterment of Black and Brown communities,” Sera said.

Despite the creative approaches that students, faculty, staff, and administrators are employing, students continue to struggle, and most of those doing this work agree that more support is still urgently needed.

“The work we do is important, but it can also be exhausting,” said Kamojjala, of Uncle Joe’s peer counseling, which operates on a volunteer basis. “Students just need more support, and this work won’t be sustainable in the long run if that doesn’t arrive.”

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Schools & Health: Our Nation's Investment.

Hardcopy Version at National Academies Press

6 Challenges in School Health Research and Evaluation

Overview Of Research And Evaluation

One of the primary arguments for establishing comprehensive school health programs (CSHPs) has been that they will improve students' academic performance and therefore improve the employability and productivity of our future adult citizens. Another argument relates to public health impact—since one-third of the Healthy People 2000 objectives can be directly attained or significantly influenced through the schools, CSHPs are seen as a means to reduce not only morbidity and mortality but also health care expenditures. It is likely that the future of CSHPs will be determined by the degree to which they are able to demonstrate a significant impact on educational and/or health outcomes.

Evaluation of any health promotion program poses numerous challenges such as measurement validity, respondent bias, attrition, and statistical power. The situation is even more challenging for CSHPs, for several reasons. First, these programs comprise multiple, interactive components, such as classroom, family, and community interventions, each employing multiple intervention strategies. Therefore, it is often difficult to determine which intervention components and specific messages, activities, and services are responsible for observed treatment effects. Second, given the broad scope of CSHPs, it is difficult to determine what the realistic outcomes should be, and measuring these outcomes in school-age children (be it the actual behavior or precursors such as communication skills) is often problematic, especially when outcomes have to do with such sensitive matters as drug use or sexual behavior. Finally, though some aspects of a CSHP (e.g., classroom curricula) can be replicated, many aspects of the CSHP (e.g., staffing patterns, local norms, and community resources) differ across schools, cities, states, and regions. Consequently, the results of even the most rigorous evaluations may not be generalizable to other settings.

This chapter examines these and other issues related to the evaluation of CSHPs. First, general principles of research and evaluation, as applied to school health programs, are reviewed. Then the challenges and difficulties associated with research and evaluation of comprehensive, multi-component programs are examined. Finally, the difficulties and uncertainties related to research and evaluation of even a single, relatively well-defined component of comprehensive programs—the health education component—are be considered. The committee felt that it was appropriate to focus on health education in this chapter, because of the relative maturity of research in this area. Specific aspects of health education research have been chosen that highlight challenges in evaluating school-based interventions, as well as in interpreting ambiguous, if not conflicting, results relevant to other components of the comprehensive program. Discussion of the research and evaluation of other components of CSHPs—health services, nutrition or foodservices, physical education, and so forth—is found in the general discussion of these components in earlier chapters.

Types of School Health Research

Research and evaluation of comprehensive school health programs can be divided into three categories: basic research, outcome evaluation, and process evaluation.

Basic Research

An ultimate goal of CSHPs is to influence behavior. Basic research in CSHPs involves inquiry into the fundamental determinants of behavior as well as mechanisms of behavior change. Basic research includes examination of factors thought to influence health behavior—such as peer norms, self-efficacy, legal factors, health knowledge, and parental attitudes—as well as specific behavior change strategies. Basic research often employs epidemiologic strategies, such as cross-sectional or longitudinal analyses, as well as pilot intervention studies designed to isolate specific behavior change strategies, although often on a smaller scale than full outcome trials. A primary function of basic behavioral research is to inform the development of interventions, whose effects can then be tested in outcome evaluation trials.

Outcome Evaluation

Outcome evaluation includes empirical examination of the impact of interventions on targeted outcomes. Possible outcomes (or dependent variables) include health knowledge, attitudes, skills, behaviors, biologic measures, morbidity, mortality, and cost-effectiveness. Interventions (or independent variables) include specific health education curricula, teaching strategies, organizational change, environmental change, or health service delivery models. This type of evaluation in its most basic form resembles the randomized clinical trial with experimental and control groups, along with the requisite null hypothesis assumptions and concern for internal and external validity. Outcome evaluation can further be divided into three stages: efficacy, effectiveness, and implementation effectiveness trials (Flay, 1986).

Efficacy . Efficacy testing involves the evaluation of an intervention under ideal, controlled implementation conditions. During this stage, for example, teachers may be paid to ensure that they implement a health curriculum, or other motivational strategies may be used to ensure fidelity. The goal of efficacy testing is to determine the potential effect of an intervention, with less concern for feasibility or replicability. In drug study parlance, during this stage of research efforts are made to ensure that the ''drug" is taken so that biologic effects, or lack thereof, can be attributed to the drug rather than to degree of compliance.

Effectiveness . In effectiveness trials, interventions are implemented under real-world circumstances with the associated variations in implementation and participant exposure. Effectiveness trials help determine if interventions can reliably be used under real-world conditions and the extent to which effects observed under efficacy conditions are reproduced in natural settings. Some programs, despite being efficacious, may not be effective if they are difficult to implement or are not accepted by staff or students. Effectiveness research is of particular concern because the results of efficacy testing and, to a lesser extent, of effectiveness trials may not always be generalizable to the real world.

Implementation Effectiveness . In implementation effectiveness trials, variations in implementation methods are manipulated experimentally and outcomes are measured (Flay, 1986). For example, the outcomes can be compared when a CSHP is implemented with or without a school coordinator or when a health education program is implemented by peers rather than adults.

Process Evaluation

Once an intervention has demonstrated adequate evidence for efficacy and effectiveness, it can be assumed that replications of the intervention will yield effects similar to those observed in prior outcomes research trials. The validity of this assumption is enhanced when multiple effectiveness trials have been successfully conducted under varying conditions and the intervention is delivered with fidelity in a setting and with a target population similar to those used in the initial testing.

It is at this point that process evaluation becomes the desired level of assessment. The goal of process evaluation is not to determine the basic impact of an intervention but rather to determine whether a proven intervention was properly implemented, and what factors may have contributed to the intervention's success or failure at the particular site. Implementation and/or participant exposure can be used as proxies for formal outcome evaluation. Key process evaluation strategies include implementation monitoring (e.g., teacher observation), quality assurance, and assessing consumer reactions (e.g., student, teacher, and parent response to the program).

Evaluation at this level may include some elements of outcome evaluation. Desired outcomes are often stated as objectives to be achieved by the program, which can be evaluated pre- and post-intervention, and may include a comparison group or references to normative data. Random selection and assignment of participants are typically not employed, however, and the level of rigor used to collect and analyze data is often less stringent than in formal outcome evaluation. This type of evaluation is sometimes referred to as program evaluation.

Although program evaluation can include rigorous design and analyses, in many real world program evaluations the assessment is often secondary to the intervention. Such interventions often do not bother with randomized design, control groups, or complex statistics. The evaluation is adapted to the intervention, rather than the inverse. For example, pragmatic issues, more than experimental design, often determine sample size and which sites are assigned to treatment or comparison conditions. In basic research and outcome evaluation on the other hand, evaluation is the principal reason that the intervention is being conducted; pragmatic issues often yield to methodologic concerns, and evaluation procedures largely are determined prior to initiating intervention activities.

Linking Outcome and Process Evaluations

Although outcome and process evaluation are described above as being sequential, the two often are conducted concurrently by linking process data to outcome data in order to determine causal pathways. One application of linking process and outcome data is the dose–response analysis—measuring the relationship between intervention dose and level of outcomes. For example, student behavioral outcomes can be examined relative to levels of teachers' curriculum implementation in a health education study or to students' level of clinic usage in a health services study. A positive dose–response relationship is seen as evidence for construct validity—that is, observed outcomes are attributed to the intervention rather than to other influences. Numerous health education studies have established a dose–response relationship between curriculum exposure and student outcomes (Connell et al., 1985; Parcel et al., 1991; Resnicow et al., 1992; Rohrbach et al., 1993; Taggart et al., 1990). Less is known about dose–response in other components of CSHPs.

Who Conducts the Research?

The various types of school health research are conducted by a diverse group of professionals. Basic research and outcome evaluation are typically conducted by doctoral-level professionals from university and freestanding research centers, often with funding from the federal government (though such studies also are supported by private foundations or corporations). Evaluating CSHPs at the level of basic research or outcome evaluation is largely beyond the fiscal and professional capacity of most local and even state education agencies. Process evaluation, on the other hand, can be conducted by local education agencies, perhaps in partnership with local public health agencies. Many models of CSHPs include an evaluation component, and it is important to delineate what type of evaluation schools and education agencies should reasonably be expected to conduct on the local level.

Although carried out by research professionals, basic research and outcome evaluation should not be abstract academic pursuits that are an end in themselves. Greater interaction is needed between researchers and those who actually implement programs. It would be desirable to stimulate and support research and evaluation alliances among colleges of education, schools of public health, and college of medicine. Bringing together the expertise from all three sectors in school health research and evaluation centers may enhance the understanding and interaction between these sectors and produce research and evaluation methods that can address cross-sector issues more accurately. This also will lead to developing programs that can be disseminated more easily and to reducing the number of researchers working in isolation.

Uses for Research and Evaluation

Basic research, outcome evaluation, and process evaluation are also conducted for different audiences and intentions. The first two are largely intended to build scientific knowledge and are generally published in the peer-reviewed literature. The latter generally is used to demonstrate feasibility of an intervention, as well as to document the facts that program implementation objectives were met and funds were properly spent. Such reports are typically requested by or intended for state education agencies, local education agencies, or funding sources that may have sponsored the local project. Local program evaluations of pilot programs also are used to justify expanding dissemination efforts.

All three types of evaluation can contribute to the development and dissemination of comprehensive school health programs, although it is important that they be applied in their proper sequence. Process evaluation studies are inappropriate for demonstrating intervention efficacy or measuring cost-effectiveness, just as basic research approaches may go beyond what is necessary for local program evaluation. To merit dissemination, programs should first undergo formal experimental efficacy and effectiveness testing; lower standards may result in adoption of suboptimal programs and ultimately impair the credibility of school health programs among their educational and public health constituencies (Ennett et al., 1994).

Methodological Challenges

Although traditional experimental studies using control or comparison groups are appropriate for testing individual program components and specific intervention strategies, this may not be the case for the overall CSHP, which is a complex entity and varies from site to site. In a recent discussion of methods to evaluate such complex systems as CSHPs, Shaw (1995) proposed that the use of the classic experimental design to conduct outcome evaluations may be outmoded and inadequate for several reasons. First, the randomized clinical trial, with its tightly controlled and defined independent and dependent variables, cannot measure and capture large-scale, rapidly changing systems. Traditional experimental design ignores the need for timely formative descriptive data, maintains the artificial roles of the researcher as external expert and the subject as passive recipient of a defined treatment, and fails to recognize the complex nature of multifaceted programs that vary according to community needs.

Furthermore, there may be ethical dilemmas in randomly assigning students to treatment versus control groups when children's health and well-being are at stake.

It will be difficult—and possibly not feasible—to conduct traditional randomized trials on entire comprehensive programs. However, interventions associated with individual program components should be developed and tested by using rigorous methods that involve experimental and control groups, with the requisite concern for internal and external validity. In this section, some of the methodological challenges of demonstrating program impacts are examined.

Challenges in Assessing Validity

A goal of studying CSHPs at the level of efficacy testing is to measure the extent to which programs produce the desired outcomes (internal validity)—that is, to determine whether there is a causal relationship between the independent variable (CSHP) and defined outcomes such as knowledge, health practices, or health status.

Defining the Independent Variable

The first measurement challenge is the difficulty in defining the independent variable (the CSHP) or "treatment." Knapp (1995) has described this dilemma: "The 'independent variable' is elusive. It can be many different kinds of things, even within the same intervention; far from being a fixed treatment, as assessed by many research designs, the target of study is more often a menu of possibilities."

Ironically, the most successful programs—which are, in fact, comprehensive, multifaceted, interdisciplinary and well integrated into the community—may be the most difficult to define and segregate into components readily identifiable as the independent variable. It may be impossible, for example, to separate effects of the school from those of the community (Perry et al., 1992). This poses an important assessment dilemma. While it is vital that comprehensive programs be evaluated as a whole (Lopez and Weiss, 1994), it is unlikely that any individual program could be replicated in its entirety in a different community with its varying infrastructure, needs, and values. Thus, internal validity—the extent to which the effectiveness of the entire program is being accurately measured—may be high, but external validity—the extent to which the findings can be generalized and replicated beyond a single setting—is sacrificed.

Because of limited resources, one might wish to prioritize individual program components based on their relative efficacy. However, the overall effect of comprehensive programs may well be more than or different from the sum of its parts. Using a factorial design to examine the effects of individual components or combinations of components would require an unwieldy number of experimental conditions and large sample size. Thus, the independent variables in a CSHP not only may be difficult to define and measure, but it is unlikely that a consensus of what should comprise the intervention can or even should be reached.

Defining the Dependent Variable

In similar ways, defining the appropriate, feasible, and measurable outcomes (dependent variables) of a CSHP is equally challenging. Is it necessary to use change in health-related behaviors, such as smoking or drug use, to measure effectiveness of health education programs, or is the acquisition of knowledge and skills sufficient? If behavior change outside the school is required to declare effectiveness, this would seem to represent an educational double standard. For example, the quality and effectiveness of mathematics education are measured by determining mathematics knowledge and skills, using some sort of school-based assessment, not by determining whether the student actually balances a checkbook or accurately fills out an income tax form as an adult. Likewise, the quality of instruction in literature or political science is measured by the acquisition of knowledge, not by whether the student writes novels, reads poetry, votes, or becomes a contributing citizen.

Similarly, should appropriate outcomes for school health services be improved health status, behaviors, and long-term health outcomes, or is simply access to and utilization of services a sufficient end point? Is a reduction in absenteeism a proxy for improved health status and a reasonable indicator of health outcomes? Dependent variables used to measure effectiveness of school-linked health services have included linking students with no prior care to health services, decreased use of the emergency room for primary care, identification of previously unidentified health problems, access to and utilization of services by students and families, perceptions and health knowledge of students and their parents, decreasing involvement in risk behaviors, and health status indicators (Glick et al., 1995; Kisker et al., 1994; Lewin-VHI and Institute of Health Policy Studies, 1995). Some of these measures simply determine whether school services provide access and utilization, whereas other measures look for a change in health status and behavior. However, if improved health status and behaviors are declared to be the expectation for school health services, does this hold the school to higher standards than those of other health care providers?

The committee points out that, although influencing health behavior and health status are ultimate goals of CSHPs, such end points involve personal decisionmaking beyond the control of the school. Other factors—family, peers, community, and the media—exert tremendous influence on students, and schools should not bear total responsibility for students' health behavior and health status. Schools should be held accountable for conveying health knowledge, providing a health-promoting environment, and ensuring access to high-quality services; these are the reasonable outcomes for judging the merit of a CSHP. 1 Other outcomes—improved attendance, better cardiovascular fitness, less drug abuse, or fewer teen pregnancies, for example—may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by personal decisionmaking and factors beyond the control of the school. In particular, null or negative outcomes for these measures should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence on children and young people oppose and outweigh the influence of the CSHP.

Other Issues

In addition to the above difficulties, all of the potential biases and challenges inherent in any research also apply. Serious threats to validity in measuring effects of CSHP include:

the Hawthorne effect—positive outcomes simply due to being part of an investigation, regardless of the nature of the intervention;
self-reporting biases—responding with answers that are thought to be "correct" and socially desirable;
Type III error—incorrectly concluding that an intervention is not effective, when in fact ineffectiveness is due to the incorrect implementation of the intervention.
ensuring even and consistent distribution of the intervention;
sorting out effects of confounding and extraneous variables;
isolating effective ingredients of multifaceted programs;
control groups that are not comparable;
differential and selective attrition in longitudinal studies;
inadequate reliability and validity of measurement tools; and
vague or inadequate conceptualization of study variables.

Another problem in drawing conclusions from reported research is "reporting bias"—the fact that only positive findings tend to be reported in the literature while studies with negative or inconclusive results are not often published. It is also important to remember that results that are statistically significant may not always have educational and public health significance.

Challenges Related to Feasibility

The kinds of large-scale research studies necessary to assess long-term outcomes of CSHPs are extremely costly and require extensive coordination. Since such programs are usually implemented for entire schools, communities, regions, or states, a majority of the children who participate are at relatively low risk for a number of outcomes of potential relevance. In addition, often only small to moderate outcome effects are sought. Hence, sample size needs are large, particularly when the unit of measurement is the school or the community rather than the individual.

Once efficacy and effectiveness have been demonstrated, the problem of developing a feasible program evaluation plan is compounded by the lack of evaluation expertise at the local or regional level and the inadequate or incompatible information systems for collecting, analyzing, and disseminating information. Local planners often need assistance in selecting and implementing evaluation strategies and in identifying means to make existing data more useful. For school health education, there are numerous guidelines and evaluation manuals from the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Service's Center for Substance Abuse Prevention at the Substance Abuse and Mental Health Services Administration, and the Educational Development Center, to help states develop an evaluation plan. The national evaluation plan for the Healthy Schools, Healthy Communities Program provides helpful information for the evaluation of school health services (Lewin-VHI and Institute of Health Policy Studies, 1995). This plan is facilitated by a standardized data collection system and marks the first time that health education and health services will be systematically analyzed with a management information system that records different types of health education interventions, utilization of health services, and outcomes.

Challenges And Future Directions For School Health Education Research

Health education is one of the essential components of CSHPs. As described in earlier chapters, health instruction has taken place in schools for many years, and the field is reasonably well defined and developed compared to some of the other aspects of a CSHP. Health education research has been an active field, but considerable knowledge gaps exist and research findings are often ambiguous, unexpected, or sometimes seemingly contradictory. This section focuses on some of the challenges and unresolved questions in classroom health education and suggests issues that merit further study.

Effects of Comprehensive Health Education

The preponderance of school health education research has consisted of outcome evaluations focusing on categorical risk behavior, such as smoking, drug use, sexual behavior, and nutrition. A few notable studies have examined several risk behaviors simultaneously—such as nutrition, physical activity, and smoking—as risk reduction interventions for cardiovascular disease or cancer (Luepker et al., 1996; Resnicow et al., 1991) or have looked at efforts to prevent drug, alcohol, and tobacco abuse (Pentz, 1989a), but there have been very few studies that evaluate comprehensive, multitopic health education programs (Connell et al., 1985; Errecart et al., 1991). The lack of evaluation studies of comprehensive health education is to a large extent the result of how school health research has been funded at the federal level. Generally, health concerns are divided into categorical areas for research and demonstration funding; the result is that funding agencies are interested in funding only research and development projects that address their particular disease area of responsibility. There is a scarcity of hard data about the potential impact of overall comprehensive classroom health education programs. Only a few commercially available multitopic school health curricula have been evaluated to test their effectiveness (e.g., the Know Your Body program). Some of these either are old and or have not made use of the methods demonstrated to be effective in categorical research and demonstration projects, which means that schools are faced with adopting programs that have not been evaluated or attempting to piece together evaluated programs.

How Much Health Education Is Enough?

There is consensus that health education programming should span kindergarten through grade 12 (Lohrman et al., 1987). However, the precise number and sequence of lessons required to achieve significant enduring effects have not been clearly defined. As mentioned previously, such determinations are complicated by uncertainties in what end points are desirable or feasible—behavior change versus change in knowledge and attitudes. If the desired end point is change in behavior, a greater dose will likely be required. ("Dose" involves two dimensions: intensity, or amount of programming per year, and duration, the number of years of programming.) Moreover, if the end point is long-term behavior change or reductions in adult morbidity and mortality, an even greater dose may be necessary that provides more intensive programming for a longer time.

The ideal means to determine adequate dose would be to deliver the same curriculum using various levels of intensity and duration and then examine differences in student outcomes by differences in curriculum exposure. However, few studies have been designed a priori to test varying format and amount of programming. Instead, most of the evidence derives from post hoc analyses examining dose–response effects between health education programming and student outcomes—that is, the relationship between level of student outcomes and how much intervention students actually received. Despite the methodologic limitations, establishing a dose–response relationship from post hoc analysis is helpful for two reasons. First, a positive dose–response relationship provides evidence for construct validity—observed changes can be attributed to the health education program rather than to other variables. Second, results of these analyses have implications regarding the proper amount and sequence of health education programming.

One of the first major studies to demonstrate a dose–response effect was the School Health Education Evaluation project (Connell et al., 1985). Students from classrooms in which health programs were implemented more fully demonstrated significantly greater improvements in attitude and behaviors, compared to the entire intervention cohort. In addition, students exposed to two years versus one year of programming showed considerably greater changes in attitudes and practices. With regard to specific dose, there was evidence that between 15 and 20 hours of classroom instruction was required to produce meaningful student effects.

Dose–response effects were also evident in the Teenage Health Teaching Modules evaluation. This study found that changes in health knowledge as well as some priority health behaviors were related to teacher proficiency and to how well teachers adhered to the program materials, although these effects were somewhat equivocal (Parcel et al., 1991). In a third study, a three-year evaluation of the Know Your Body program, Resnicow et al. (1992) found significantly larger intervention effects for blood lipids, systolic blood pressure, health knowledge, self-efficacy, and dietary behavior among students exposed to "high-implementation" teachers relative to moderate- and low-implementation teachers, as well as to comparison youth receiving no programming.

There is additional evidence regarding dose–response from a survey conducted for the Metropolitan Life Insurance Company in 1988. This survey of 4,738 students in grades 3 through 12 in 199 public schools revealed that as the years of health instruction increased, students' health-related knowledge and healthy habits increased. With one year of health instruction, 43 percent of the students drank alcohol ''sometimes or more often," a level that decreased to 33 percent for students who had received three years of health instruction. With only one year of health instruction, 13 percent of the students had taken drugs, compared with only 6 percent who had received three years of health instruction. In regard to exercising outside of the school, 80 percent of the students who had three years of health instruction did so, but only 72 percent of those who had one year of instruction exercised outside of school (Harris, 1988).

Duration, Sequence, and Timing of Health Education

Two other aspects of dose include intensity of programming (i.e., concentrated versus dispersed) and booster treatments. With regard to the former, Botvin and colleagues (1983) found that students who received a substance use education program several times a week for 4 to 6 weeks (a "concentrated" format) showed stronger treatment effects than youth receiving the program once a week for 12 weeks (a "dispersed" format). Additionally, in two separate studies, students receiving booster sessions following a year of primary intervention showed larger and more sustained behavior effects than youth receiving only the initial intervention (Botvin et al., 1983; Botvin et al., 1995). Taken together, these findings suggest that the greater the intensity and duration of health education programming, the greater is the effect. It is important to note that "increased dose" can include two elements. The first relates to the number of lessons contained in a curriculum; the second is a function of implementation fidelity on the part of classroom teachers. Thus, a complex, non-user-friendly health education program containing many lessons may, due to low teacher implementation, result in a lower dose than will a more user-friendly program containing fewer lessons.

With regard to specific policy recommendations, there are insufficient data to delineate a requisite number of lessons across content areas and grades. There is, however, some evidence to suggest that at least 10 to 15 initial lessons, plus 8 to 15 booster sessions in subsequent years, are required to produce lasting behavioral effects (Botvin et al., 1983, 1995; Connell et al., 1985). These data, however, are derived primarily from substance use prevention studies of middle school youth. Little is known about the requisite intensity and duration of programming for other content areas or other age groups. It is also unclear to what extent general life skills training, which targets substance use or sexual risk behaviors, may positively influence other behavioral domains. If spillover, synergistic effects from skills training or other common elements of health education programs (e.g., modifying normative expectations and increasing self-efficacy) occur when categorical programs are delivered within a comprehensive framework, the total number of lessons ultimately required for comprehensive curricula may be fewer than the sum of lessons from isolated categorical programs.

Additionally, whether these findings, which are based on a categorical topic, can be applied to a comprehensive curriculum merits discussion. It may be necessary to stagger content across K–12 and to target programming by developmental needs. For example, programming could be concentrated more heavily on substance use prevention at the middle school level, while in primary grades, nutrition and safety education could comprise the areas of focus. This developmental needs approach is a deviation from currently proposed curriculum frameworks, which suggest that health education address 8 to 12 content areas at each grade level. In view of the research that suggests a minimal number of lessons per grade for each content area, more serious attention should be given to setting priority areas for each stage of student development.

Lasting Effects of School Health Education

In several long-term follow-up studies of substance prevention programs delivered in grades 5 through 8 (Bell et al., 1993; Flay et al., 1989; Murray et al., 1989), positive program effects observed one to four years following the intervention had decayed by grade 12, or shortly after graduation from high school. Decay of program effects has also been observed for curricula addressing other content areas (Bush et al., 1989). There are studies, however, in which behavioral effects decayed but significant effects for knowledge and attitude were maintained (Bell et al., 1993; Flay et al., 1995).

Recently, however, Botvin and colleagues (1995) reported positive long-term results in a study involving more than 3,500 students in grade 12 who were randomly assigned to receive either the Life Skills Training substance use prevention program in grades 7 through 9 or "treatment as usual." Significant reductions in tobacco, alcohol, and marijuana use were evident at the follow-up in grade 12, and effects were greater among students whose teachers taught the program with higher fidelity (i.e., high implementors).

How can the positive effects reported by Botvin et al. be reconciled with the null results reported in prior studies? One explanation is dose. The previous interventions comprised only six to eight lessons in the first year and, in the Ellickson and Bell (1990) and Flay et al. (1989) studies, three to five booster sessions in subsequent years. Botvin's intervention contained 15 lessons in the first year and 15 additional lessons over the next two years. Other explanations include superiority of the Life Skills Training curriculum, including its content, format, and teacher training procedures, as well as higher levels of teacher implementation. Although the results of Botvin's study of substance use prevention are encouraging, research regarding the optimal dose and timing of curricula addressing other health behaviors is still needed. Given that achieving change in language arts and mathematics skills requires daily instruction for 12 academic years, it is reasonable to conclude that changes in health knowledge and in health behaviors also will require more instruction than one semester, the standard middle and secondary school requirement.

Active Ingredients of Health Education

Many successful health education programs employ several conceptually diverse intervention strategies such as didactic, affective, and behavioral activities directed at students, as well as environmental and policy change. Although there is considerable evidence that such programs as a whole can work, the construct validity of specific subcomponents—that is, "why" programs achieve or fail to achieve their desired effects—remains unclear (McCaul and Glasgow, 1985). Consider, for example, skills training. During the 1980s, numerous skills-based interventions aimed at increasing general and behavior-specific skills were developed and evaluated (Botvin et al., 1984; Donaldson et al., 1995; Flay, 1985; Kirby, 1992; McCaul and Glasgow, 1985). While initial results were encouraging and skills training has become an integral component of many school health education programs (Botvin et al., 1980; CDC, 1988, 1994; Flay, 1985; Glynn, 1989; Kirby, 1992; Pentz et al., 1989b; Schinke et al., 1985; Walter et al., 1988), many "skills-based" programs include other intervention strategies, such as modifying personal and group norms and outcome expectations, which also many have contributed to the reported intervention effects (Botvin et al., 1984; Ellickson and Bell, 1990; Murray et al., 1989; Pentz et al., 1989a; Walter et al., 1987). Several studies specifically designed to test the independent effects of skills training have found this approach to be largely ineffective (Elder et al., 1993; Hansen and Graham, 1991; Sussman et al., 1993). Instead, these studies indicate that modifying normative beliefs—students' assumptions regarding the prevalence and acceptability of substance use—appears to be the ''active ingredient" of many of the skills training programs. Despite the questionable effectiveness of skills training in substance use prevention, skills may be important in other behavioral domains such as sexuality, nutrition, and exercise (Baranowksi, 1989; Perry et al., 1990; Sikkema et al., 1995; St. Lawrence et al., 1995; Warzak et al., 1995).

Similarly, although there is acceptance on the part of many health educators that peers are effective "messengers," the evidence for the effectiveness of peer-based health education is also somewhat equivocal (Bangert-Drowns, 1988; Clarke et al., 1986; Ellickson et al., 1993; Johnson et al., 1986; McCaul and Glasgow, 1985; Murray et al., 1988; Perry et al., 1989; Telch et al., 1990). The effectiveness of peer-based programs is likely to depend more on how peers are included in the program than on simply having peer-led activities.

In a review of programs to reduce sexual risk behavior, Kirby and coworkers found several differences between programs that had an impact on behavior and those that did not (Kirby et al., 1994). Although the authors warn that generalizations must be made cautiously, ineffective curricula tended to be broader and less focused. Effective curricula clearly focused on the specific values, norms, and skills necessary to avoid sex or unprotected sex, whereas ineffective curricula covered a broad range of topics and discussed many values and skills. Interestingly, the length of the program or the amount of skills practice did not appear to predict the success of programs. The authors suggest, however, that skills practice may be effective only when clear values or norms are emphasized or when skills focus specifically on avoiding undesirable sexual behavior rather than on developing more general communication skills.

Given the limited funding and classroom time available for health education, it is important that school health education programs include primarily those approaches known to influence health behavior. Providing health information is a necessary but certainly not sufficient condition for affecting behavior. Identifying "active ingredients" can be achieved through factorial designs as well as post hoc statistical techniques such as structural models, and discriminant analysis can be used to elucidate mediating variables and specific intervention components that may account for program effects (Botvin and Dusenbury, 1992; Dielman et al., 1989; MacKinnon et al., 1991).

Risk-Factor-Specific Versus Problem Behavior Intervention Models

Numerous studies have found that "problem" behaviors—such as the use of alcohol, marijuana, and tobacco; precocious sexual involvement; and delinquent activity—are positively correlated and occur in clusters. Problem Behavior Theory proposes an underlying psychologic phenomenon of "unconventionality" as the unifying etiologic explanation (see Basen-Engquist et al., 1996; Donovan and Jessor, 1985; Donovan et al., 1988; Resnicow et al., 1995). This conceptualization of health behavior has significant implications for CSHPs. As opposed to commonly used risk-factor-specific interventions that deal with each behavior separately, Problem Behavior Theory suggests that high-risk and problem behaviors can be prevented by an intervention that addresses common predisposing causes. Such interventions may be not only more effective but also more efficient, since fewer total lessons may be required to alter the common "core" causes. In addition to generic interventions, it may also be necessary to apply general strategies to selected high-risk behaviors. However, most school systems do not conceptualize health education from this perspective. Instead, health instruction is broken down into discrete content areas, more akin to the risk-factor-specific approach. Additional research, particularly studies examining the effects of interventions addressing traits that may underlie clusters of risk behaviors, is needed before health education is restructured toward a more targeted model of health behavior change.

Realistic Outcomes for School Health Education

It can be argued that previous studies reporting weak or null behavioral outcomes employed health education interventions of insufficient dose and breadth. Many of the interventions had no more than 10 lessons, delivered over the course of one year, and few or no subsequent booster lessons. As noted earlier, the positive long-term behavioral effects reported by Botvin and colleagues (1995) may be attributed largely to the increased dose. Additionally, had the categorical programs for which no long-term behavioral effects were observed been delivered within the context of a comprehensive school health program, positive effects may have been observed. It is important to set realistic expectations for school health education, particularly since many of the programs used in our schools provide a dose of insufficient intensity and duration, whose effects are further attenuated by inadequate levels of teacher implementation. As stated earlier, although influencing behavior is an ultimate goal of school health education, schools should not bear the total responsibility for student behavior, given all the other influences on students—family, peers, the media, community norms, and expectations—that are beyond the control of the school. Schools should be held accountable for providing a high-quality, up-to-date health education program that is delivered by qualified teachers using curricula that are based on research and have been validated through outcome evaluation. Schools should be held responsible for arming students with the knowledge, attitudes, and skills to adopt health-enhancing behavior and to avoid health-compromising behavior. If these conditions are met but behavioral outcomes are still less than desired, then other sources of influence on students must be examined for alignment with school health education messages. In addition, there may be delayed effects on behavior in later life, even if no immediate behavioral impacts are observed.

There is encouraging evidence that when school-based interventions are delivered along with complementary community-wide or media campaigns, significant long-term behavioral effects can be achieved (Flynn et al., 1994; Kelder et al., 1993; Perry et al., 1992; see Flay et al., 1995, for an exception). Therefore, although health education delivered in isolation may not be able to produce lasting behavioral effects, when combined with other activities or implemented within a comprehensive school health program, significant enduring changes in behavior as well as physical risk factors can be achieved.

There is considerable evidence that comprehensive curricula can produce significant short-term effects on multiple health behaviors, including substance use, diet, and exercise (Bush et al., 1989; Connell et al., 1985; Errecart et al., 1991; Resnicow et al., 1992; Walter et al., 1988, 1989). However, many of the assumptions regarding the effectiveness of classroom health education derive from studies of categorical programs, and it is unclear to what degree the effects observed for categorical programs are diminished or magnified when taught within a comprehensive framework. Although it can be argued that incorporating categorical programs within a comprehensive framework would attenuate effects because the focus on any one behavior or health issue would be diminished, it could also be argued that program effects would be enhanced because comprehensive programs provide extended if not synergistic application and reinforcement of essential skills across a wide range of topics. This is another area that calls for further research.

Summary Of Findings And Conclusions

Research and evaluation of CSHPs can be divided into three categories: basic research, outcome evaluation, and process evaluation. Basic research involves inquiry into the fundamental determinants of behavior as well as mechanisms of behavior change. A primary function of basic research is to inform the development of interventions that can then be tested in outcome evaluation trials. Outcome evaluation involves the empirical examination of interventions on targeted outcomes, based on the randomized clinical trial approach with experimental and control groups. Process evaluation determines whether a proven intervention was properly implemented and examines factors that may have contributed to the intervention's success or failure. Basic research and outcome evaluation are typically conducted by professionals from university or other research centers and are largely beyond the capacity of local education agencies.

The committee believes that process evaluation is the appropriate level of evaluation in local programs.

Research and evaluation are particularly challenging for CSHPs. Since these programs comprise multiple interactive components, it is often difficult to attribute observed effects to specific components or to separate program effects from those of the family or community. Determining what outcomes are realistic and measuring outcomes in students are often problematic, especially when outcomes involve sensitive matters such as drug use or sexual behavior. Furthermore, since CSHPs are unique to a particular setting, the results of even the most rigorous evaluations may not be generalizable to other situations.

Interventions associated with the separate, individual components of CSHPs—health education, health services, nutrition services, and so forth—should be developed and tested using rigorous methods involving experimental and control groups. However, such an approach is likely to be difficult—and possibly not feasible—for studying entire comprehensive programs or determining the differential effects of individual components and combinations of components.

A fundamental issue involves determining what outcomes are appropriate and reasonable to expect from CSHPs. The committee recognizes that although influencing health behavior and health status is an ultimate goal of a CSHP, such end points involve factors beyond the control of the school. The committee believes that the reasonable outcomes on which a CSHP should be judged are equipping students with the knowledge, attitudes, and skills necessary for healthful behavior; providing a health-promoting environment; and ensuring access to high-quality services. Other outcomes—improved cardiovascular fitness or a reduction in absenteeism, drug abuse, or teen pregnancies, for example—may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by factors beyond the control of the school. In particular, null or negative measures for these outcomes should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence oppose and outweigh that of the CSHP or that the financial investment in the CSHP is so limited that returns are minimal.

Recommendations

In order for CSHPs to accomplish the desired goal of influencing behavior, the committee recommends the following:

An active research agenda on comprehensive school health programs should be pursued in order to fill critical knowledge gaps; increased emphasis should be placed on basic research and outcome evaluation and on the dissemination of these research and outcome findings.

Research is needed about the effectiveness of specific intervention strategies such as skills training, normative education, or peer education; the effectiveness of specific intervention messages such as abstinence versus harm reduction; and the required intensity and duration of health education programming. Evidence suggests that common underlying factors may be responsible for the clustering of health-compromising behaviors and that interventions may be more effective if they address these underlying factors in addition to intervening to change risk behaviors. Additional research is needed to understand the etiology of problem behavior clusters and to develop optimal problem behavior interventions. And finally, since the acquisition of health-related social skills—such as negotiation, decisionmaking, and refusal skills—is a desired end point of CSHPs, basic research is needed to develop valid measures of social skills that can then be used as proxy measures of program effectiveness. Diffusion-related research is critical to ensure that efforts of research and development lead to improved practice and a greater utilization of effective methods and programs. Therefore, high priority should be given to studying how programs are adopted, implemented, and institutionalized. The feasibility and effectiveness of techniques of integrating concepts of health into science and other school subjects should also be examined.

Since the overall effects of comprehensive school health programs are not yet known and outcome evaluation of such complex systems poses significant challenges, the committee recommends the following:

A major research effort should be launched to establish model comprehensive programs and develop approaches for their study.

Specific outcomes of overall programs should be examined, including education (improved achievement, attendance, and graduation rates), personal health (resistance to "new social morbidities," improved biologic measures), mental health (less depression, stress, and violence), improved functionality, health systems (more students with a "medical home," reduction in use of emergency rooms or hospitals), self-sufficiency (pursuit of higher education or job), and future health literacy and health status. Studies could look at differential impacts of programs produced by such factors as program structure, characteristics of students, and type of school and community.

A thorough understanding of the feasible and effective (including cost-effective) interventions in each separate area of a CSHP will be necessary to provide the basis for combining components to produce a comprehensive program.

The committee recommends that further study of each of the individual components of a CSHP—for example, health education, health services, counseling, nutrition, school environment—is needed.

Additional studies are needed in a number of other areas. First, more data are needed about the advantages (cost and effectiveness) and disadvantages of providing health and social services in schools compared to other community sites—or compared to not providing services anywhere—as a function of community and student characteristics. This information will require overall consensus about the criteria to use for determining the quality of school health programs. It is also important to know how best to influence change in the climate and organizational structure of school districts and individual schools in order to bring about the adoption and implementation of CSHPs. Finally, there is a need for an analysis of the optimal structure, operation, and personnel needs of CSHPs.

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This view is consistent with earlier discussion in this chapter that for the local school, the desired level of evaluation is process evaluation. If the school is providing health curricula and health services that have been shown through basic research and outcome evaluation to produce positive health outcomes, the committee suggests that the crucial question at the school level should be whether the interventions are implemented properly.

Cite this Page Institute of Medicine (US) Committee on Comprehensive School Health Programs in Grades K-12; Allensworth D, Lawson E, Nicholson L, et al., editors. Schools & Health: Our Nation's Investment. Washington (DC): National Academies Press (US); 1997. 6, Challenges in School Health Research and Evaluation.
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Published: 27 April 2022

School educational models and child mental health among K-12 students: a scoping review

Ting Yu 1 ,
Jian Xu 1 ,
Yining Jiang 1 ,
Hui Hua 1 ,
Yulai Zhou 1 &
Xiangrong Guo 1 , 2

Child and Adolescent Psychiatry and Mental Health volume 16 , Article number: 32 ( 2022 ) Cite this article

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The promotion of mental health among children and adolescents is a public health imperative worldwide, and schools have been proposed as the primary and targeted settings for mental health promotion for students in grades K-12. This review sought to provide a comprehensive understanding of key factors involved in models of school education contributing to student mental health development, interrelationships among these factors and the cross-cultural differences across nations and societies.

This scoping review followed the framework of Arksey and O’Malley and holistically reviewed the current evidence on the potential impacts of school-related factors or school-based interventions on student mental health in recent 5 years based on the PubMed, Web of Science, Embase and PsycExtra databases.

Results/findings

After screening 558 full-texts, this review contained a total of 197 original articles on school education and student mental health. Based on the five key factors (including curriculum, homework and tests, physical activities, interpersonal relationships and after-school activities) identified in student mental development according to thematic analyses, a multi-component school educational model integrating academic, social and physical factors was proposed so as to conceptualize the five school-based dimensions for K-12 students to promote student mental health development.

Conclusions

The lessons learned from previous studies indicate that developing multi-component school strategies to promote student mental health remains a major challenge. This review may help establish appropriate school educational models and call for a greater emphasis on advancement of student mental health in the K-12 school context among different nations or societies.

Introduction

In recent years, mental health conditions among children and adolescents have received considerable attention as a public health concern. Globally about 10–20% of children and adolescents experience mental health problems [ 1 , 2 ], and mental health problems in early life may have the potential for long-term adverse consequences [ 3 , 4 ]. In 2019, the World Health Organization has pointed out that childhood and adolescence are critical periods for the acquisition of socio-emotional capabilities and for prevention of mental health problems [ 5 ]. A comprehensive multi-level solution to child mental health problems needs to be put forward for the sake of a healthier lifestyle and environment for future generations.

The school is a unique resource to help children improve their mental health. A few generations ago, schools’ priority was to teach the traditional subjects, such as reading, writing, and arithmetic. However, children are now spending a large amount of time at school where they learn, play and socialize. For some students, schools have a positive influence on their mental health. While for others, schools can present as a considerable source of stress, worry, and unhappiness, and hinder academic achievement [ 2 ]. According to Greenberg et al., today’s schools need to teach beyond basic skills (such as reading, writing, and counting skills) and enhance students’ social-emotional competence, characters, health, and civic engagement [ 6 ]. Therefore, universal mental health promotion in school settings is recognized to be particularly effective in improving students’ emotional well-being [ 2 , 7 ].

Research evidence over the last two decades has shown that schools can make a difference to students’ mental health [ 8 ]. Previous related systematic reviews or meta-analyses focused on the effects of a particular school-based intervention on child mental health [ 9 , 10 ] and answered a specific question with available research, however, reviews covering different school-related factors or school-based interventions are still lacking. An appropriate model of school education requires the combination of different school-related factors (such as curriculum, homework, and physical activities) and therefore needs to focus on multiple primary outcomes. Thus, we consider that a scoping review may be more appropriate to help us synthesize the recent evidence than a systematic review or meta-analysis, as the wide coverage and the heterogeneous nature of related literature focusing on multiple primary outcomes are not amenable to a more precise systematic review or meta-analysis [ 11 ]. To the best of our knowledge, this review is among the first to provide a comprehensive overview of available evidence on the potential impacts of multiple school-related factors or school-based interventions on student mental health, and identify school-related risk/protective factors involved in the development of mental health problems among K-12 students, and therefore, to help develop a holistic model of K-12 education.

A scoping review was systematically conducted following the methodological framework of Arksey and O'Malley [ 12 ]: defining the research question; identifying relevant studies; study selection; data extraction; and summarizing and reporting results. The protocol for this review was specified in advance and submitted for registration in the PROSPERO database (Reference number, CRD42019123126).

Defining the research question (stage 1)

For this review, we sought to answer the following questions:

What is known from the existing literature on the potential impacts of school-related factors or school-based interventions on student mental health?

What are the interrelationships among these factors involved in the school educational process?

What are the cross-cultural differences in K-12 education process across nations and societies?

Identifying relevant studies (stage 2)

The search was conducted in PubMed, Web of Science and Embase electronic databases, and the dates of the published articles included in the search were limited to the last 5 years until 23 March 2021. The PsycExtra database was also searched to identify relevant evidence in the grey literature [ 13 ]. In recent 5 years, mental disorders among children and adolescents have increased at an alarming rate [ 14 , 15 ] and relevant policies calling for a greater role of schools in promoting student mental health have been issued in different countries [ 16 , 17 , 18 ], making educational settings at the forefront of the prevention initiative globally. Therefore, limiting research source published in the past 5 years was pre-defined since these publications reflected the newest discoveries, theories, processes, or practices. Search terms were selected based on the eligibility criteria and outcomes of interest were described as follows (Additional file 1 : Table S1). The search strategy was peer-reviewed by the librarian of Shanghai Jiao Tong University School of Medicine.

Study selection (stage 3)

T.Y. and Y.J. independently identified relevant articles by screening the titles, reviewing the abstracts and full-text articles. If any disagreement arises, the disagreement shall be resolved by discussion between the two reviewers and a third reviewer (J. X.).

Inclusion criteria were (1) according to the study designs: only randomized controlled trials (RCT)/quasi-RCT, longitudinal and cross-sectional studies; (2) according to the languages: articles only published in English or Chinese; (3) according to the ages of the subjects: preschoolers (3.5–5 years of age), children (6–11 years of age) and adolescents (12–18 years of age); and (4) according to the study topics: only articles examining the associations between factors involved in the school education and student mental health outcomes (psychological distress, such as depression, anxiety, stress, self-injury, suicide; and/or psychological well-being, such as self-esteem, self-concept, self-efficacy, optimism and happiness) in educational settings. Exclusion criteria: (1) Conference abstracts, case report/series, and descriptive articles were excluded due to overall quality and reliability. (2) Studies investigating problems potentially on a causal pathway to mental health disorders but without close associations with school education models (such as problems probably caused by family backgrounds) were excluded. (3) Studies using schools as the recruitment places but without school-related topics were also excluded.

Data extraction (stage 4)

T.Y. and Y.J., and X.G., Y. Z., H.H. extracted data from the included studies using a pre-defined extraction sheet. Researchers extracted the following information from each eligible study: study background (name of the first author, publication year, and study location), sample characteristics (number of participants, ages of participants, and sex proportion), design [intervention (RCT or quasi-RCT), or observational (cross-sectional or longitudinal) study], and instruments used to assess exposures in school settings and mental health outcomes. For intervention studies (RCTs and quasi-RCTs), we also extracted weeks of intervention, descriptions of the program, duration and frequency. T.Y. reviewed all the data extraction sheets under the supervision of J. X.

Summarizing and reporting the results (stage 5)

Results were summarized and reported using a narrative synthesis approach. Studies were sorted according to (a) factors/exposures associated with child and adolescent mental health in educational settings, and (b) components of school-based interventions to facilitate student mental health development. Key findings from the studies were then compared, contrasted and synthesized to illuminate themes which appeared across multiple investigations.

Search results and characteristics of the included articles

The search yielded 25,338 citations, from which 558 were screened in full-text. Finally, a total of 197 original articles were included in this scoping review: 72 RCTs (including individually randomized and cluster-randomized trials), 27 quasi-RCTs, 29 longitudinal studies and 69 cross-sectional studies (Fig. 1 for details). Based on thematic analyses, the included studies were analyzed and thematically grouped into five overarching categories based on the common themes in the types of intervention programs or exposures in the school context: curriculum, homework and tests, interpersonal relationships, physical activity and after-school activities. Table 1 provided a numerical summary of the characteristics of the included articles. The 197 articles included data from 46 countries in total, covering 24 European countries, 13 Asian countries, 4 American countries, 3 African countries, and 2 Oceanian countries. Most intervention studies were conducted in the United States of America (n = 16), followed by Australia (n = 11) and the United Kingdom (n = 11). Most observational studies were conducted in the United States of America (n = 19), followed by China (n = 15) and Canada (n = 8). Figure 2 illustrated the geographical distribution of the included studies. Further detailed descriptions of the intervention studies or observational studies were provided in Additional file 1 : Tables S2 and S3, respectively.

Study selection process

Geographical distribution of included studies: A intervention studies; B observational studies

The association between school curriculum and student mental health was investigated in four cross-sectional studies. Mathematics performance was found to be adversely associated with levels of anxiety or negative emotional responses among primary school students [ 19 ]. However, in middle schools, difficulties and stressors students may encounter in learning academic lessons (such as difficulties/stressors in taking notes and understanding teachers’ instructions) could contribute to lowered self-esteem [ 20 ] and increased suicidal ideation or attempts [ 21 ]. Innovative integration of different courses instead of the traditional approach of teaching biology, chemistry, and physics separately, could improve students’ self-concept [ 22 ].

To promote student mental health, 64 intervention studies were involved in innovative curricula integrating different types of competencies, including social emotional learning (SEL), mindfulness-intervention, cognitive behavioral therapy (CBT)-based curriculum, life skills training, stress management curriculum, and so on (Fig. 3 ). Curricula focusing on SEL put an emphasis on the development of child social-emotional skills such as managing emotions, coping skills and empathy [ 23 ], and showed positive effects on depression, anxiety, stress, negative affect and emotional problems [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ], especially in children with psychological symptoms [ 24 ] and girls [ 23 , 27 ], as well as increased prosocial behaviors [ 38 ], self-esteem [ 39 , 40 , 41 , 42 ] and positive affect [ 43 ]. However, four programs reported non-significant effects of SEL on student mental health outcomes [ 44 , 45 , 46 , 47 ], while two programs demonstrated increased levels of anxiety [ 48 ] and a reduction of subjective well-being [ 49 ] at post-intervention. Mindfulness-based curriculum showed its potential to endorse positive outcomes for youth including reduced emotional problems and negative affect [ 50 , 51 , 52 , 53 , 54 , 55 , 56 ] as well as increased well-being and positive emotions [ 51 , 52 , 57 , 58 , 59 , 60 ], especially among high-risk children with emotional problems or perceived stress before interventions [ 50 , 53 ]. However, non-significant effects were also reported in an Australian study in secondary schools [ 61 ]. Curricula based on CBT targeted children at risk or with early symptoms of mental illness [ 62 , 63 , 64 , 65 , 66 , 67 ], or all students regardless of symptom levels as a universal program [ 68 , 69 , 70 ], and could impose a positive effect on self-esteem, well-being, distress, stress and suicidality. However, a universal CBT trial in Swedish primary schools found no evidence of long-term effects of such program on anxiety prevention [ 71 ]. Five intervention studies based on life-skill-training were found to be effective in promoting self-efficacy [ 72 , 73 ], self-esteem [ 73 , 74 ], and reducing depression/anxiety-like symptoms [ 72 , 75 , 76 ]. Courses covering stress management skills have also been reported to improve life satisfaction, increase happiness and decrease anxiety levels among students in developing countries [ 77 , 78 , 79 ]. In practice, innovative teaching forms such as the game play [ 67 , 80 , 81 ] and outdoor learning [ 82 , 83 ] embedded in the traditional classes could help address the mental health and social participation concerns for children and youth. Limited evidence supported the mental health benefits of resilience-based curricula [ 84 , 85 , 86 ], which deserve further studies.

Harvest plots for overview of curriculum-based intervention studies, grouped by different types of curriculum-based interventions. The height of the bars corresponded to the sample sizes on a logarithmic scale of each study. Red bars represented positive effects of interventions on student mental health outcomes, grey bars represented non-significant effects on student mental health outcomes, and black bars represented negative effects on student mental health outcomes

Large cluster-randomized trials utilizing multi-component whole-school interventions which involves various aspects of school life (curriculum, interpersonal relationships, activities), such as the Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health (SEHER) program in India and the Together at School program in Finland, have been proved to be beneficial for prevention from depression [ 87 , 88 , 89 ] and psychological problems [ 90 ].

Homework and tests

The association between homework and psychological ill-being outcomes was investigated in four cross-sectional studies and one longitudinal study. Incomplete homework and longer homework durations were associated with a higher risk of anxiety symptoms [ 91 , 92 ], negative emotions [ 93 , 94 , 95 ] and even psychological distress in adulthood [ 96 ].

Innumerable exams during the educational process starting from primary schools may lead to increased anxiety and depression levels [ 97 , 98 ], particularly among senior students preparing for college entrance examinations [ 99 ]. Students with higher test scores had a lower probability to have emotional and behavioral problems [ 100 ], in comparison with students who failed examinations [ 93 , 101 ]. Depression and test anxiety were found to be highly correlated [ 102 ]. In terms of psychological well-being outcomes, findings were consistent in the negative associations between student test anxiety and self-esteem/life-satisfaction levels [ 103 , 104 ]. Regarding intervention studies, adolescent students at a high risk of test anxiety benefited from CBT or attention training by strengthening sense of control and meta-cognitive beliefs [ 105 , 106 ]. However, more knowledge about the criteria for an upcoming test was not related to anxiety levels during lessons [ 107 ].

Interpersonal relationships

School-based interpersonal (student–student or student–teacher) relationships are also important to student mental health. Low support from schoolmates/teachers and negative interpersonal events were reported to be associated with psychosomatic health complaints [ 108 , 109 , 110 , 111 , 112 , 113 ]. In contrast, positive interpersonal relationships in schools could promote emotional well-being [ 114 , 115 , 116 , 117 ] and reduce depressive symptoms in students [ 118 , 119 , 120 ].

Student–teacher relationships

Negative teaching behaviors were associated with negative affect [ 121 , 122 ] and low self-efficacy [ 123 ] among primary and high school students. Student–teacher conflicts at the beginning of the school year were associated with higher anxiety levels in students at the end of the year, and high-achieving girls were most susceptible to such negative associations [ 124 ]. Higher levels of perceived teachers’ support were correlated with decreased risks of depression [ 125 ], mental health problems [ 126 ] as well as increased positive affect [ 127 , 128 ] and improved mental well-being [ 129 , 130 ]. Better student–teacher relationships were positively associated with self-esteem/efficacy [ 131 ], while negatively associated with the risks of adolescents’ externalizing behaviors [ 132 ] among secondary school students. Longitudinal studies demonstrated that high intimacy levels between students and teachers were correlated with reduced emotional symptoms [ 133 ] and increased life-satisfaction among students [ 134 ]. In addition, more respect to teachers in 10th grade students was associated with higher self-efficacy and lower stress levels 1 year later [ 135 ].

A growing body of research focused on the issue of how to increase positive interactions between teachers and students in teaching practices. Actually, interventions on improving teaching skills to promote a positive classroom atmosphere could potentially benefit children, especially those experiencing a moderate to high level of risks of mental health problems [ 136 , 137 ].

Student–student relationships

Findings were consistent in considering the positive peer relationship as a protective factor against internalizing and externalizing behaviors [ 138 , 139 , 140 , 141 , 142 ], depression [ 143 , 144 , 145 ], anxiety [ 146 ], self-harm [ 147 ] and suicide [ 148 ], and as a favorable factor for positive affect [ 149 , 150 ], increased happiness [ 151 ], self-efficacy [ 152 ], optimism [ 153 , 154 ] and mental well-being [ 155 ]. In contrast, peer-hassles, friendlessness, negative peer-beliefs, peer-conflicts/isolation and peer-rejection, have been identified in the development of psychological distress among students [ 141 , 143 , 149 , 156 , 157 , 158 , 159 , 160 , 161 , 162 , 163 , 164 , 165 ].

As schools and classrooms are common settings to build peer relationships, student social skills to enhance the student–student relationship can be incorporated into school education. Training of interpersonal skills among secondary school students with depressive symptoms appeared to be effective in decreasing adolescent internalizing and externalizing symptoms [ 166 ]. In addition, recent studies also identified the effectiveness of small-group learning activities in the cognitive development and mental health promotion among students [ 87 , 88 , 89 , 90 , 167 ].

Physical activity in school

Moderate-to-high-intensity physical activity during school days has been confirmed to benefit children and adolescents in relation to various psychosocial outcomes, such as reduced symptoms of depression [ 168 ], emotional problems [ 169 ] and mental distress [ 170 ] as well as improved self-efficacy [ 171 ] and mental well-being [ 172 , 173 ]. In addition, participation in physical education (PE) at least twice a week was significantly associated with a lower likelihood of suicidal ideation and stress [ 174 ].

A variety of school‐based physical activity interventions or lessons have been proposed in previous studies to promote physical activity levels and psychosocial fitness in students, including integrating physical activities into classroom settings [ 175 , 176 , 177 , 178 ], assigning physical activity homework [ 178 ], physically-active academic lessons [ 179 , 180 ] as well as an obligation of ensuring the participation of various kinds of sports (such as aerobic exercises, resistance exercises, yoga) in PE lessons [ 181 , 182 , 183 , 184 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 ]. Although the effectiveness of these proposed physical activity interventions was not consistent, physical education is suggested to implement sustainably as other academic courses with special attention.

After-school activities

Several cross-sectional studies have synthesized evidence on the positive effects of leisure-time physical activity against student depression, anxiety, stress, and psychological distress [ 193 , 194 , 195 , 196 , 197 , 198 , 199 ]. Extracurricular sport participation (such as sports, dance, and martial arts) could foster perceived self-efficacy, self-esteem, improve mental health status [ 200 , 201 , 202 , 203 ], and reduce emotional problems [ 204 ] and depressive symptoms [ 205 ]. Participation in team sports was more strongly related to beneficial mental health outcomes than individual sports, especially in high school girls [ 199 ]. Other forms of organized activities, such as youth organizations and arts, have also been demonstrated to benefit self-esteem [ 201 ], self-worth [ 206 ], satisfaction with life and optimism [ 207 , 208 ].

However, different types of after-school activities may result in different impacts on student mental health. Previous studies demonstrated that students participating in after-school programs of yoga or sports had better well-being and self-efficacy [ 209 ], and decreased levels of anxiety [ 210 ] and negative mood [ 211 ], while another study showed that the after-school yoga program induced no significant changes in levels of depression, anxiety and stress among students [ 212 ]. Inconsistent findings on the effects of participation in art activities on student mental health were also reported [ 213 , 214 ]. Another study also highlighted the benefits of after-school clubs, demonstrating an improvement in socio-emotional competencies and emotional status, and sustained effects at 12-month follow-up [ 215 ].

Based on the potential importance of the five school-based factors identified in student mental development, a multi-component school educational model is therefore proposed to conceptualize the five school-based dimensions (including curriculum, homework and tests, interpersonal relationships, physical activity, and after-school activities) for K-12 students to promote their mental health (Fig. 4 ). The interrelationships among the five dimensions and cross-cultural comparisons are further discussed as follows in a holistic way.

The multi-component school educational model is proposed to conceptualize the five school-based dimensions (including curriculum set, homework and tests, physical activity, interpersonal relationships and after-school activities) for K-12 students to promote student mental health

Comprehensive understanding of K-12 school educational models: the reciprocal relationships among factors

Students’ experiences in the school educational context are dynamic processes which englobe a variety of educational elements (such as curriculum, homework, tests) and social elements (such as interpersonal relationships and social activities in schools). Based on the educational model proposed in this review, these educational/social elements are closely related and interact with each other, which play an important role in students’ psychosocial development.

Being aware of this, initiatives aimed to improve student social and emotional competencies may certainly impact student psychological well-being, at least in part, in a way of developing supportive relationships between teachers-students or between peers [ 35 , 89 ]. On the other hand, the enhancement of interpersonal relationships at school could serve as a potent source of motivation for student academic progress so as to further promote psychological well-being [ 131 , 132 ]. In addition, school education reforms intended to provide pupils with more varied teaching and learning practices to promote supportive interpersonal relationships between students and teachers or between peers, such as education programs outside the classroom [ 82 ], cooperative learning [ 167 ] and adaptive classroom management [ 136 , 137 ], have also been advocated among nations recently.

Our findings also suggested that participation in non-academic activities was an important component of positive youth development. Actually, these school-based activities in different contexts also require teacher–student interactions or peer interactions. Social aspects of physical activities have been proposed to strengthen relationship-building and other interpersonal skills that may additionally protect students against the development of mental health problems [ 130 , 203 ]. Among various types of sports, team sports seemed to be associated with more beneficial outcomes compared with individual sports due to the social aspect of being part of a team [ 194 , 199 ]. Participation in music, student council, and other clubs/organizations may also provide students with frequent connections with peers, and opportunities to build relationships with others that share similar interests [ 201 ]. Further, frequent and supportive interactions with teachers and peers in sports and clubs may promote student positive views of the self and encourage their health-promoting behaviors (such as physical activities).

However, due to increasing academic pressure, children have to spend a large amount of time on academic studies, and inevitably displace time on sleep, leisure, exercises/sports, and extracurricular activities [ 92 ]. Although the right amount of homework may improve school achievements [ 216 ] and higher test scores may help prevent students from mental distress [ 100 , 101 , 102 ], over-emphasis on academic achivements may lead to elevated stress levels and poor health outcomes ultimately. The anxiety specifically related to academic achievement and test-taking at school was frequently reported among students who felt pressured and overwhelmed by the continuous evaluation of their academic performance [ 98 , 103 , 104 ]. In such high-pressure academic environments, strategies to alleviate the levels of stress among students should be incorporated into intervention efforts, such as stress management skill training [ 77 , 78 , 79 ], CBT-based curriculum [ 62 , 64 , 66 , 105 ], and attention training [ 106 ]. Therefore, school supportive policies that allow students continued access to various non-academic activities as well as improve their social aspect of participation may be one fruitful avenue to promote student well-being.

Cross-cultural differences in K-12 educational models among different nations and societies

As we reviewed above, heavy academic burden exists as an important school-related stressor for students [ 91 , 92 , 94 , 95 , 96 ], probably due to excessive examinations [ 97 , 98 , 99 ] and unsatisfactory academic performance [ 100 , 101 , 102 ]. Actually, extrinsic cultural factors significantly impact upon student academic burden. In most countries, college admission policies affect the entire ecological system of K-12 education, because success in life or careers is determined by examination performance to a large extent [ 217 ]. The impacts of heavy academic burden may be greatest in Asian cultures where more after-school time of students is spent on homework, exam preparations, and extracurricular classes for academic improvement (such as in Korea, Japan, China and Singapore) [ 92 , 95 , 218 ]. As a consequence, the high proportion of adolescents fall in the “academic burnout group” in Asian countries [ 219 ], which highlights the need to take further measures to combat the issue. As an issue of concern, the “double reduction” policy has been implemented nationwide in China since 2021, being aimed to relieve students of excessive study burden, and the effects of the policy are anticipated but remain unknown up to now.

Other factors such as school curriculum and extra-curricular commitments, vary among societies and nations and may explain the cross-cultural differences in educational models [ 220 ]. For example, in Finland, the primary science subject is as important as mathematics or reading, while Chinese schools often lack time to arrange a sufficient number of science courses [ 221 ], which could be explained by different educational traditions of the two countries. In addition, approximately 75% of high schools in Korea failed to implement national curriculum guidelines for physical education (150 min/week), instead replacing that time with self-guided study to prepare for university admission exams [ 174 ]. In terms of the arrangement of the after-school time, Asian students spend most of their after-school time on private tutoring or doing homework [ 222 ], 2–3 times longer than the time spent by adolescents in most western countries/cities [ 92 ]. However, according to our analyses and summaries, most intervention studies targeting the improvement of mental health of students by school education were conducted in western countries (Fig. 2 ), suggesting that special attention needs to be paid to the students’ mental health issue on campus, especially in countries where students have heavy study-loads. Merits of the different educational traditions also need to be considered in the designs of educational models among different countries.

Strengths and limitations

This study focuses on an interdisciplinary topic covering the fields of developmental behavioral pediatrics and education, and the establishment of appropriate school educational models is teamwork involving multiple disciplines including pediatrics, prevention, education, services and policy. Although there are lots of studies focusing on a particular factor in school educational processes to promote student mental health, comprehensive analysis/understanding on multi-component educational model is lacking, which is important and urgently needed for the development of multi-dimensional educational models/strategies. Therefore, we included a wide range of related studies, summarized a comprehensive understanding of the evidence base, and discussed the interrelationships among the components/factors of school educational models and the cross-cultural gaps in K-12 education across different societies, which may have significant implications for future policy-making.

Some limitations also exist and are worth noting. First, this review used the method of the scoping review which adopted a descriptive approach, rather than the meta-analysis or systematic review which provided a rigorous method of synthesizing the literature. Under the subject (appropriate school education model among K-12 students) of this scoping review, multiple related topics (including curriculum, homework and tests, physical activities, interpersonal relationships and after-school activities) were included rather than one specific topic. Therefore, we consider that the method of the scoping-review is appropriate, given that the aim of this review is to chart or map the available literature on a given subject rather than answering a specific question by providing effect sizes across multiple studies. Second, we limited the study search within recent 5 years. Although we consider that the fields involved in this scoping review change quickly with the acquisition of new knowledge/information in recent 5 years, limiting the literature search within recent 5 years may make us miss some related but relatively old literature. Third, we only included studies disseminated in English or Chinese, which may limit the generalizability of our results to other non-English/Chinese speaking countries.

This scoping review has revealed that the K-12 schools are unique settings where almost all the children and adolescents can be reached, and through which existing educational components (such as curriculum, homework and tests, physical activities, interpersonal relationships and after-school activities) can be leveraged and integrated to form a holistic model of school education, and therefore to promote student mental health. In future, the school may be considered as an ideal setting to implement school-based mental health interventions. Our review suggests the need of comprehensive multi-component educational model, which involves academic, social and physical factors, to be established to improve student academic achievement and simultaneously maintain their mental health.

However, questions still remain as to what is optimal integration of various educational components to form the best model of school education, and how to promote the wide application of the appropriate school educational model. Individual differences among students/schools and cross-cultural differences may need to be considered in the model design process.

Availability of data and materials

The data analysed in this review are available from the corresponding author upon request.

Abbreviations

Cognitive behavioral therapy

Physical education

Randomized controlled trials

Social emotional learning

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Acknowledgements

We thank the librarian of Shanghai Jiao Tong University School of Medicine for their help.

This study was supported by the National Natural Science Foundation of China (NSFC, 81974486, 81673189) (to Jian Xu), Shanghai Jiao Tong University School of Medicine Gaofeng Clinical Medicine Grant Support (20172016) (to Jian Xu), Shanghai Sailing Program (21YF1451500) (to Hui Hua).

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Ting Yu, Jian Xu, Yining Jiang, Hui Hua, Yulai Zhou & Xiangrong Guo

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JX conceived the scoping review, supervised the review process and reviewed the manuscript. TY conducted study selection and data extraction, charted, synthesized the data, and drafted the manuscript. YJ conducted study selection and data extraction. XG, YZ and HH conducted data extraction. All authors read and approved the final manuscript.

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Additional file 1: table s1..

Search strategies used for each database. Table S2 . Summaries of intervention studies (randomized/quasi-randomized controlled trials) investigating the effects of school-based interventions on child mental health (n = 99). Table S3. Summaries of observational research on relationships between school-related factors and student mental health outcomes (n = 98).

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Yu, T., Xu, J., Jiang, Y. et al. School educational models and child mental health among K-12 students: a scoping review. Child Adolesc Psychiatry Ment Health 16 , 32 (2022). https://doi.org/10.1186/s13034-022-00469-8

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School health education research: future issues and challenges

PMID: 6565117

This paper presents the view that the dissemination of effective school health education constitutes a significant problem that deserves high priority on a national research agenda for school health education. Justification of dissemination is grounded in two presuppositions: (1) that there is a positive correlation between health education and the practice of health-enhancing behaviors and (2) that health education is an appropriate and fundamental task for schools. Two complex sub-problems are discussed. The first is related to the fact that there are no data to help us determine how many children in this country actually receive health information in schools. In addition, there is insufficient evidence to ascertain either the quality or quantity of health information children receive or where in the curriculum the presentation of that information occurs. The second problem pertains to the myriad of complex factors that impede the implementation of health education in schools. These two problems are re-cast into a series of researchable questions.

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DOI: 10.26666/rmp.jssh.2023.6.4
Corpus ID: 268565759

The Effects of Mental Health Issues and Academic Performance

Arianta Rachmana , Aini Syahira Jamaluddin
Published in Journal of social sciences… 30 December 2023
Psychology, Education

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Survey of the field. Proportions of students with mental health problems and/or experiencing excessive school demands increased between 1988 and 2011 in Sweden (Nygren & Hagquist, Citation 2019), in accordance with international trends (Bains & Diallo, Citation 2016).Schools inevitably influence their mental health (Suldo, McMahan, Chappel, & Loker, Citation 2012; Wells et al., Citation 2003 ...
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The Impact of School Mental Health on Student and School-Level Academic Outcomes: Current Status of the Research and Future Directions

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How Do We Know If a School Mental Health Intervention Is Effective: An Introduction to the Section on the State of the Science for School Mental Health Interventions

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Student mental health is in crisis. Campuses are rethinking their approach

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A culture of wellness

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Schools & Health: Our Nation's Investment.

6 Challenges in School Health Research and Evaluation

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School educational models and child mental health among K-12 students: a scoping review

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Physical activity in school

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Comprehensive understanding of K-12 school educational models: the reciprocal relationships among factors

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Child and Adolescent Psychiatry and Mental Health

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School health education research: future issues and challenges

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