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A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties

  • Joanna K. Anderson (a1), Tamsin Ford (a2), Emma Soneson (a3), Jo Thompson Coon (a2), Ayla Humphrey (a3), Morwenna Rogers (a2), Darren Moore (a4), Peter B. Jones (a3), Emmet Clarke (a5) and Emma Howarth (a1)...



Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.


Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3–18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.


We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.


Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.

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Corresponding author

Author for correspondence: Joanna K. Anderson, E-mail:


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Armijo Olivo, S, Stiles, CR, Hagen, NA, Biondo, PD and Cummings, GG (2012) Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration risk of bias tool and the effective public health practice project quality assessment tool: methodological research. Journal of Evaluation in Clinical Practice 18, 1218.
Auger, RW (2000) An examination of teachers’ ability to identify middle school students with depressive characteristics. In Education University of Iowa: University of Iowa.
Auger, RW (2004) The accuracy of teacher reports in the identification of middle school students With depressive symptomatology. Psychology in the Schools 41, 379389.
Bowen, DJ, Kreuter, M, Spring, B, Cofta-Woerpel, L, Linnan, L, Weiner, D, Bakken, S, Kaplan, CP, Squiers, L, Fabrizio, C and Fernandez, M (2009) How we design feasibility studies. American Journal of Preventive Medicine 36, 452457.
Bruhn, AL, Woods-Groves, S and Huddle, S (2014) A preliminary investigation of emotional and behavioral screening practices in K-12 schools. Education & Treatment of Children 37, 611634.
Burke, LA, Wasserman, D, Carli, V, Corcoran, P, Keeley, H, Balazs, J, Bobes, J, Apter, A, Brunner, R, Cosman, D, Haring, C, Pierre Kahn, J, Marusic, D, Postuvan, V, Saiz, P and Varik, A (2013) A cost effectiveness analysis of four arms of a school-based mental health intervention in Europe. European Child and Adolescent Psychiatry 1, S198S199.
Burns, BJ, Costello, EJ, Angold, A, Tweed, D, Stangl, D, Farmer, EM and Erkanli, A (1995) Children's mental health service use across service sectors. Health Affairs 14, 147159.
Caldarella, P, Young, EL, Richardson, MJ, Young, BJ and Young, KR (2008) Validation of the systematic screening for behavior disorders in middle and junior high school. Journal of Emotional and Behavioral Disorders 16, 105117.
Campbell, MA (2004) Identification of ‘at-risk’ students for prevention and early intervention programs in secondary schools. Australian Journal of Guidance and Counselling 14, 6577.
Carter, G, Milner, A, McGill, K, Pirkis, J, Kapur, N and Spittal, MJ (2017) Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. The British Journal of Psychiatry 210, 387395.
Cohen, JF, Korevaar, DA, Altman, DG, Bruns, DE, Gatsonis, CA, Hooft, L, Irwig, L, Levine, D, Reitsma, JB, De Vet, HC and Bossuyt, PM (2016) STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 6, e012799.
Cotter, P, Kaess, M, Corcoran, P, Parzer, P, Brunner, R, Keeley, H, Carli, V, Wasserman, C, Hoven, C, Sarchiapone, M, Apter, A, Balazs, J, Bobes, J, Cosman, D, Haring, C, Kahn, JP, Resch, F, Postuvan, V, Varnik, A and Wasserman, D (2015) Help-seeking behaviour following school-based screening for current suicidality among European adolescents. Social Psychiatry and Psychiatric Epidemiology 50, 973982.
Cunningham, JM and Suldo, SM (2014) Accuracy of teachers in identifying elementary school students who report at-risk levels of anxiety and depression. School Mental Health 6, 237250.
D'Souza, CM, Forman, SF and Austin, SB (2005) Follow-up evaluation of a high school eating disorders screening program: knowledge, awareness and self-referral. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine 36, 208213.
Deeks, JJ, Dinnes, J, D'Amico, R, Sowden, AJ, Sakarovitch, C, Song, F, Petticrew, M and Altman, DG (2003) Evaluating non-randomised intervention studies. Health Technology Assessment 7, 3173.
Dowdy, E, Doane, K, Eklund, K and Dever, BV (2013) A comparison of teacher nomination and screening to identify behavioral and emotional risk within a sample of underrepresented students. Journal of Emotional and Behavioral Disorders 21, 127137.
Dowdy, E, Dever, BV, Raines, TC and Moffa, K (2016) A preliminary investigation into the added value of multiple gates and informants in universal screening for behavioral and emotional risk. Journal of Applied School Psychology 32, 178198.
Dwyer, SB, Nicholson, JM and Battistutta, D (2006) Parent and teacher identification of children at risk of developing internalizing or externalizing mental health problems: a comparison of screening methods. Prevention Science 7, 343357.
Eklund, K and Dowdy, E (2014) Screening for behavioral and emotional risk versus traditional school identification methods. School Mental Health 6, 4049.
Eklund, K, Renshaw, TL, Dowdy, E, Jimerson, SR, Hart, SR, Jones, CN and Earhart, J (2009) Early identification of behavioral and emotional problems in youth: universal screening versus teacher-referral identification. California School Psychologist 14, 8995.
Fletcher, A, Jamal, F, Moore, G, Evans, RE, Murphy, S and Bonell, C (2016) Realist complex intervention science: applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions. . Evaluation & Research in Education 22, 286303.
Ford, T, Sayal, K and Meltzer, H and Goodman, R (2005) Parental concerns about their child's emotions and behaviour and referral to specialist services: general population survey. Bmj December 15, 14351436.
Ford, T, Hamilton, H, Meltzer, H and Goodman, R (2007) Child mental health is everybody's business: the prevalence of contact with public sector services by type of disorder among British school children in a three-year period. Child and Adolescent Mental Health 12, 1320.
Ford, T, Hamilton, H, Meltzer, H and Goodman, R (2008) Predictors of service use for mental health problems among British schoolchildren. Child and Adolescent Mental Health 13, 3240.
Forness, SR, Cluett, SE, Ramey, CT, Ramey, SL, Zima, BT, Hsu, C, Kavale, KA and MacMillan, DL (1998) Special education identification of head start children with emotional and behavioral disorders in second grade. Journal of Emotional and Behavioral Disorders 6, 194204.
Garland, AF (1995) Pathways to adolescent mental health services: adolescent help-seeking and teacher identification and referral. In Faculty of the Graduate School. US: Yale University.
Girio-Herrera, E, Owens, JS and Langberg, JM (2013) Perceived barriers to help-seeking among parents of at-risk kindergarteners in rural communities. Journal of Clinical Child and Adolescent Psychology 42, 6877.
Gould, MS, Marrocco, FA, Hoagwood, K, Kleinman, M, Amakawa, L and Altschuler, E (2009) Service use by at-risk youths after school-based suicide screening. Journal of the American Academy of Child and Adolescent Psychiatry 48, 11931201.
Green, H, McGinnity, Á, Meltzer, H, Ford, T and Goodman, R (2005) Mental Health of Children and Young People in Great Britain, 2004. Palgrave Macmillan: Basingstoke.
Hallfors, D, Cho, H, Brodish, PH, Flewelling, R and Khatapoush, S (2006) Identifying high school students “at risk” for substance use and other behavioral problems: implications for prevention. Substance Use and Misuse 41, 115.
Hilt, LM, Tuschner, RF, Salentine, C, Torcasso, G and Nelson, KR (2018) Development and initial psychometrics of a school-based screening program to prevent adolescent suicide. Practice Innovations 3, 117.
Hoffmann, TC, Glasziou, PP, Boutron, I, Milne, R, Perera, R, Moher, D, Altman, DG, Barbour, V, Macdonald, H, Johnston, M and Lamb, SE (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. Bmj 348, g1687.
Howarth, E, Devers, K, Moore, G, O'Cathain, A and Dixon-Woods, M (2016) Contextual issues and qualitative research. In Challenges, Solutions and Future Directions in the Evaluation of Service Innovations in Health Care and Public Health. Health Services and Delivery Research 4(16), pp. 136.
Husky, MM, Kaplan, A, McGuire, L, Flynn, L, Chrostowski, C and Olfson, M (2011) Identifying adolescents at risk through voluntary school-based mental health screening. Journal of Adolescence 34, 505511.
Joint Commissioning Panel for Mental Health (2013) Guidance for commissioners of children and adolescent mental health services.
Jones, P (2013) Adult mental health disorders and their age at onset. The British Journal of Psychiatry 202, s5s10.
Jones, D, Dodge, KA, Foster, EM and Nix, R (2002) Early identification of children at risk for costly mental health service use. Prevention Science : the Official Journal of the Society for Prevention Research 3, 247256.
Jones, DE, Greenberg, M and Crowley, M (2015) Early social-emotional functioning and public health: the relationship between kindergarten social competence and future wellness. American Journal of Public Health 105, 22832290.
Kieling, RR, Kieling, C, Aguiar, AP, Costa, AC, Dorneles, BV and Rohde, LA (2014) Searching for the best approach to assess teachers’ perception of inattention and hyperactivity problems at school. European Child & Adolescent Psychiatry 23, 451459.
Kilgus, S, Taylor, C, Van, MW and Sims, W (2018) Diagnostic accuracy of a universal screening multiple gating procedure: a replication study. School Psychology Quarterly.
Knapp, M and Iemmi, V (2013) The economic case for better mental health. In Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. Department of Health, pp. 147156.
Lyon, AR, Maras, MA, Pate, CM, Igusa, T and Vander Stoep, A (2015) Modeling the impact of school-based universal depression screening on additional service capacity needs: a system dynamics approach. Administration and Policy in Mental Health and Mental Health Services Research 43, 168188.
Maggin, DM and Johnson, AH (2015) The reporting of core program components: an overlooked barrier for moving research into practice. Preventing school failure. Alternative Education for Children and Youth 59, 7382.
McLaughlin, RJ, Holcomb, JD, Jibaja-Rusth, ML and Webb, JA (1993) Teacher ratings of student risk for substance use as a function of specialized training. Journal of Drug Education 23, 8395.
Mitchell, SG, Gryczynski, J, Gonzales, A, Moseley, A, Peterson, T, O'Grady, KE and Schwartz, RP (2012) Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program: services and outcomes. The American Journal on Addictions/American Academy of Psychiatrists in Alcoholism And Addictions 21, S5S13.
Morey, ME, Arora, P and Stark, KD (2015) Multiple-stage screening of youth depression in schools. Psychology in the Schools 52, 800814.
Naser, S (2014) Evaluating the Utility of the Behavioral and Emotional Screening System (BESS) as a School-Based Universal Screening Tool. Tulane University School of Science and Engineering.
Nemeroff, R, Levitt, JM, Faul, L, Wonpat-Borja, A, Bufferd, S, Setterberg, S and Jensen, PS (2008) Establishing ongoing, early identification programs for mental health problems in our schools: a feasibility study. Journal of the American Academy of Child & Adolescent Psychiatry 47, 328338.
Oakley, A, Strange, V, Bonell, C, Allen, E and Stephenson, J (2006) Process evaluation in randomised controlled trials of complex interventions. Bmj 332, 413416.
Ollendick, TH, Greene, RW, Weist, MD and Oswald, DP (1990) The predictive validity of teacher nominations: a five-year followup of at-risk youth. Journal of Abnormal Child Psychology 18, 699713.
Popay, J, Roberts, H, Sowden, AJ, Petticrew, M, Arai, L, Rodgers, M, Britten, N, Roen, K and Duffy, S (2006) Guidance on the conduct of narrative synthesis in systematic reviews. A Product from the ESRC Methods Programme Version 1, b92.
Robinson, J, Gook, S, Yuen, HP, Hughes, A, Dodd, S, Bapat, S, Schwass, W, McGorry, P and Yung, AR (2010) Depression education and identification in schools: an Australian-based study. School Mental Health 2, 1322.
Robinson, J, Yuen, HP, Martin, C, Hughes, A, Baksheev, GN, Dodd, S, Bapat, S, Schwass, W, McGorry, P and Yung, AR (2011) Does screening high school students for psychological distress, deliberate self-harm, or suicidal ideation cause distress - and is it acceptable? Crisis 32, 254263.
Sayal, K, Owen, V, White, K, Merrell, C, Tymms, P and Taylor, E (2010) Impact of early school-based screening and intervention programs for ADHD on children's outcomes and access to services: follow-up of a school-based trial at age 10 years. Archives of Pediatrics & Adolescent Medicine 164, 462469, 8p.
Scott, MA, Wilcox, HC, Schonfeld, IS, Davies, M, Hicks, RC, Turner, JB and Shaffer, D (2009) School-based screening to identify at-risk students not already known to school professionals: the Columbia suicide screen. American Journal of Public Health 99, 334339.
Sweeney, C, Warner, CM, Brice, C, Stewart, C, Ryan, J, Loeb, KL and McGrath, RE (2015) Identification of social anxiety in schools: the utility of a two-step screening process. Contemporary School Psychology 19, 268275.
Tisher, M (1995) Teachers’ assessments of prepubertal childhood depression. Australian Journal of Psychology 47, 9396.
Tyne, TF and Flynn, JT (1981) Teacher nominations and peer evaluations in the identification of socioemotional at-risk students. Exceptional Children 48, 6668.
Wells, M, Williams, B, Treweek, S, Coyle, J and Taylor, J (2012) Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials 13, 95.
Whitney, SD, Renner, LM, Pate, CM and Jacobs, KA (2011) Principals’ perceptions of benefits and barriers to school-based suicide prevention programs. Children and Youth Services Review 33, 869877.


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