The goal of much observational research is to identify risk factors that have a causal effect on health and social outcomes. However, observational data are subject to biases from confounding, selection and measurement, which can result in an underestimate or overestimate of the effect of interest. Various advanced statistical approaches exist that offer certain advantages in terms of addressing these potential biases. However, although these statistical approaches have different underlying statistical assumptions, in practice they cannot always completely remove key sources of bias; therefore, using design-based approaches to improve causal inference is also important. Here it is the design of the study that addresses the problem of potential bias - either by ensuring it is not present (under certain assumptions) or by comparing results across methods with different sources and direction of potential bias. The distinction between statistical and design-based approaches is not an absolute one, but it provides a framework for triangulation - the thoughtful application of multiple approaches (e.g. statistical and design based), each with their own strengths and weaknesses, and in particular sources and directions of bias. It is unlikely that any single method can provide a definite answer to a causal question, but the triangulation of evidence provided by different approaches can provide a stronger basis for causal inference. Triangulation can be considered part of wider efforts to improve the transparency and robustness of scientific research, and the wider scientific infrastructure and system of incentives.

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Causal inference with observational data: the need for triangulation of evidence

There are increasing rates of internalising difficulties, particularly anxiety and depression, being reported in children and young people in England. School-based, universal prevention programmes are thought to be one way of helping tackle such difficulties. This protocol describes a four-arm cluster randomised controlled trial, investigating the effectiveness of three different interventions when compared to usual provision, in English primary and secondary pupils. The primary outcome for Mindfulness and Relaxation interventions is a measure of internalising difficulties, while Strategies for Safety and Wellbeing will be examined in relation to intended help-seeking. In addition to the effectiveness analysis, a process and implementation evaluation and a cost-effectiveness evaluation will be undertaken. Overall, 160 primary schools and 64 secondary schools will be recruited across England. This corresponds to 17,600 participants. Measures will be collected online at baseline, 3–6 months later, and 9–12 months after the commencement of the intervention. An economic evaluation will assess the cost-effectiveness of the interventions. Moreover, a process and implementation evaluation (including a qualitative research component) will explore several aspects of implementation (fidelity, quality, dosage, reach, participant responsiveness, adaptations), social validity (acceptability, appropriateness and feasibility), and their moderating effects on the outcomes of interest, and perceived impact. This trial aims to address important questions about whether schools’ practices around the promotion of mental wellbeing and the prevention of mental health problems can: (1) be formalised into feasible and effective models of school-based support and (2) whether these practices and their effects can be sustained over time. Given the focus of these interventions on mirroring popular practice in schools and on prioritising approaches that present low-burden, high-acceptability to schools, if proved effective, and cost-effective, the findings will indicate models that are not only empirically tested but also offer high potential for widespread use and, therefore, potentially widespread benefits beyond the life of the trial. ISRCTN16386254. Registered on 30 August 2018.

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Promoting mental health and wellbeing in schools: Examining Mindfulness, Relaxation and Strategies for Safety and Wellbeing in English Primary and Secondary Schools: Study Protocol for a Multi-school, Cluster Randomised Controlled Trial (INSPIRE)

Psychological distress among primary school teachers: a comparison with clinical and population samples

BACKGROUND There is limited research that explores the association between exclusion from school and mental health, but it seems intuitively plausible that the recognition of mental difficulties by key teachers and parents would influence the likelihood of exclusion from school. METHODS A secondary analysis of the British Child and Adolescent Mental Health survey 2004, (n = 7997) and the 2007 follow-up (n = 5326) was conducted. Recognition of difficulty was assessed via a derived variable that combined the first item of the Impact supplement of the Strengths and Difficulties Questionnaire which asked parents and teachers if they thought that the child has difficulties with emotions, behaviour and concentration, and the presence/absence of psychiatric disorder measured by the Development and Well-being Assessment. RESULTS Adjusted logistic regression models demonstrated that children with recognised difficulties were more likely to be excluded [adjusted odds ratio (OR) 5.78, confidence interval 3.45-9.64, p < 0.001], but children with unrecognised difficulties [adjusted OR 3.58 (1.46-8.81) p < 0.005] or recognised subclinical difficulties [adjusted OR 3.42 (2.04-5.73) p < 0.001] were also more likely to be excluded than children with no difficulties. Children with conduct disorder and attention deficit hyperactivity disorder were most likely to be excluded compared with other types of disorder. CONCLUSION Exclusion from school may result from a failure to provide timely and effective support rather than a failure to recognise psychopathology.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/7FE7132AC36B160DFDF97D25342F1686/S0033291718003513a.pdf/div-class-title-are-children-with-unrecognised-psychiatric-disorders-being-excluded-from-school-a-secondary-analysis-of-the-british-child-and-adolescent-mental-health-surveys-2004-and-2007-div.pdf

Are children with unrecognised psychiatric disorders being excluded from school? A secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007.

Children’s early problematic behaviour correlates with later deviant behaviour. The Incredible Years Teacher Classroom Management (IY TCM) program trains teachers in proactive strategies to disrupt patterns of negative child behaviour. This mixed methods systematic review applies multilevel meta-analysis and qualitative meta-synthesis to answer: What is known about the effectiveness of IY TCM, and how do people experience the program and its effects? We included RCTs comparing IY TCM against treatment-as-usual/waitlist controls and interview/focus group studies with stakeholders. We pooled effect sizes using multilevel metaanalysis and applied grounded theory analysis to qualitative data. We used framework analysis and integrative grids for cross-synthesis. Nine studies from England, Ireland, Jamaica, the United States, and Wales were included. IY TCM significantly reduced teachers’ use of negative classroom management strategies and reduced conduct problems among high-risk children. No significant effects were found for improving child prosocial behaviours. Qualitative findings illuminated iterative learning processes between the individual and group and identified a wider range of perceived benefits than was measured in trials. Cross-synthesis demonstrates both harmonious overlap and gaps from differing research priorities. IY TCM presents an opportunity to lessen violence in schools, leading to improved learning environments for all. It reduced teachers’ negative classroom management practices and high-risk children’s aggressive/non-compliant behaviours. Experiential data mirrors these findings and expands upon them with a wide range of perceived benefits, demonstrating IY TCM MIXED METHODS SYSTEMATIC REVIEW OF INCREDIBLE YEARS 3 is acceptable and enjoyable. Future quantitative research should seek to test the processes produced in the qualitative meta-synthesis, to better understand mechanisms of change.

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Mixed methods systematic review on effectiveness and experiences of the Incredible Years Teacher Classroom Management programme

BackgroundWe evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools’ important influence on child mental health.MethodsA two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes. Trial registration: ISRCTN84130388.ResultsEighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = −1.0; 95% CI−1.9 to −0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health.ConclusionsTCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.

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The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial.

Background Poor mental health in childhood is common, persistent and associated with a range of adverse outcomes that include persistent psychopathology, as well as risk-taking behaviour, criminality and educational failure, all of which may also compromise health. There is a growing policy focus on children’s mental health and the role of schools in particular in addressing this. Objectives To evaluate whether or not the Incredible Years® (IY) Teacher Classroom Management (TCM) training improved children’s mental health, behaviour, educational attainment and enjoyment of school, improved teachers’ mental health and relationship with work, and was cost-effective in relation to potential improvements. Design A two-arm, pragmatic, parallel-group, superiority, cluster randomised controlled trial. Setting A total of 80 UK schools (clusters) were recruited in three distinct cohorts between 2012 and 2014 and randomised to TCM (intervention) or teaching as usual [(TAU) control] with follow-ups at 9, 18 and 30 months. Schools and teachers were not masked to allocation. Participants Eighty schools (n = 2075 children) were randomised: 40 (n = 1037 children) to TCM and 40 (n = 1038 children) to TAU. Interventions TCM was delivered to teachers in six whole-day sessions, spread over 6 months. The explicit goals of TCM are to enhance classroom management skills and improve teacher–student relationships. Main outcome measures The primary planned outcome was the teacher-reported Strengths and Difficulties Questionnaire Total Difficulties (SDQ-TD) score. Random-effects linear regression and marginal logistic regression models using generalized estimating equations were used to analyse outcomes. Results The intervention reduced the SDQ-TD score at 9 months [adjusted mean difference (AMD) –1.0, 95% confidence interval (CI) –1.9 to –0.1; p = 0.03] but there was little evidence of effects at 18 months (AMD –0.1, 95% CI –1.5 to 1.2; p = 0.85) and 30 months (AMD –0.7, 95% CI –1.9 to 0.4; p = 0.23). Planned subgroup analyses suggested that TCM is more effective than TAU for children with poor mental health. Cost-effectiveness analysis using the SDQ-TD suggested that the probability of TCM being cost-effective compared with TAU was associated with some uncertainty (range of 40% to 80% depending on the willingness to pay for a unit improvement in SDQ-TD score). In terms of quality-adjusted life-years (QALYs), there was evidence to suggest that TCM was cost-effective compared with TAU at the National Institute for Health and Care Excellence thresholds of £20,000–30,000 per QALY at 9- and 18-month follow-up, but not at 30-month follow-up. There was evidence of reduced disruptive behaviour (p = 0.04) and reductions in inattention and overactivity (p = 0.02) at the 30-month follow-up. Despite no main effect on educational attainment, subgroup analysis indicated that the intervention’s effect differed between those who did and those who did not have poor mental health for both literacy (interaction p = 0.04) and numeracy (interaction p = 0.03). Independent blind observations and qualitative feedback from teachers suggested that teachers’ behaviour in the classroom changed as a result of attending TCM training. Limitations Teachers were not masked to allocation and attrition was marked for parent-reported data. Conclusions Our findings provide tentative evidence that TCM may be an effective universal child mental health intervention in the short term, particularly for primary school children who are identified as struggling, and it may be a cost-effective intervention in the short term. Future work Further research should explore TCM as a whole-school approach by training all school staff and should evaluate the impact of TCM on academic progress in a more thorough and systematic manner. Trial registration Current Controlled Trials ISRCTN84130388. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 6. See the NIHR Journals Library website for further project information. Funding was also provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (NIHR CLAHRC South West Peninsula).

Training teachers in classroom management to improve mental health in primary school children: the STARS cluster RCT

Alternative approaches to mental health and support programming for military veterans and for officers of the Royal Canadian Mounted Police (RCMP) with occupational stress injuries have recently received attention in the field of post-traumatic stress. The purpose of this study was to evaluate the experiences of military veterans and actively serving RCMP officers with occupational stress injuries who participated in an exploratory study using an equine-assisted learning program. Using a focus group research design, 20 veterans and five RCMP officers were interviewed about their experiences in a 4-week equine-assisted learning program. A thematic content analysis, following Braun and Clarke’s (2006) method, revealed five main themes: (1) appreciation for the value of learning new skills, (2) connection with the horse in terms of the human–animal bond, (3) self-regulation and learning to “speak horse,” (4) sense of accomplishment and competence, and (5) transferable skills to everyday life. The qualitative findings of this study provide support for the use of equine-assisted learning programming with military veterans and RCMP members and demonstrate potential as an alternative therapeutic intervention for occupational stress injuries in these populations.

Katie Grimes

Papers

The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial.

Training teachers in classroom management to improve mental health in primary school children: the STARS cluster RCT

Equine Programs for Military Veterans and RCMP Officers with Occupational Stress Injuries: A Qualitative Analysis