A national school-based mental health program that is now reaching almost one quarter of all elementary school students in Chile appears to have produced significant improvements in both behavioral and academic outcomes, such as attention problems and school attendance, among participating students. The results of a study by a team of Chilean and U.S. investigators appear in the October issue of the Journal of the American Academy of Child & Adolescent Psychiatry.
J. Michael Murphy, EdD, of the Massachusetts General Hospital (MGH)
, senior author of the JAACAP paper, notes that this is the first study to document the positive impact of a large-scale pediatric mental health intervention using validated mental health measures and real-world benchmarks like end-of-the-year promotion and school attendance. “These findings suggest that school-based mental health programs could play an important role in achieving better educational outcomes for whole countries as well as individual children. Our findings also provide evidence that non-pharmacological interventions can be effective. ”
First author Javier Guzmán of the Universidad del Desarrollo in Chile was national coordinator of the Chilean Skills for Life (Habilidades para la Vida) program from 2008-2014 and is now a Glenn Fellow doctoral student at Boston University Graduate School of Education. He explains that the program was established almost two decades ago when the Chilean department of education added mental health concerns to programs addressing problems in areas like vision, hearing and nutrition offered through the National Association of School Assistance and Scholarship (Junta Nacional de Auxilio Escolar y Becas or JUNAEB).
A multidisciplinary team of child psychologists, psychiatrists, pediatricians and educators from Chile consulted with some of the world’s leading child mental health experts to create a program based on the best available research, eventually adopting an approach that taught key mental health skills in a child-, parent- and teacher-friendly manner. Starting out in a handful of schools in 2001, the program is now offered in more than 1,600 schools.
First-grade students in participating schools are screened with surveys completed by their parents – a Chilean version of the MGH-developed Pediatric Symptoms Checklist – and by their teachers. The surveys ask about symptoms of anxiety, depression, attention and conduct problems, along with evaluating students’ disruptiveness, emotional maturity and concentration in the classroom. Children identified by the surveys as at risk for psychosocial problems are offered a series of workshops during second grade – ten for the students, three for their parents and two for their teachers.
The student workshops are led by psychologists or social workers and include innovative techniques for social and emotional learning – including physical activities and arts and crafts projects designed to teach children concepts such as respect for themselves and others, the importance of keeping their word and following directions. Both parent surveys – used to identify problems like depression that may not be evident in school – and teacher surveys are repeated for all students in third grade so that the impact of the program can be evaluated.
The current study began with a sample of more than 40,000 students who were screened in first grade. Of the approximately 4,000 who were identified as at risk for mental health problems and offered the ten-session group intervention during second grade, those who participated in a greater number of sessions showed significantly greater improvements in third-grade outcomes than did the at-risk students who participated in fewer sessions. The Skills for Life program also includes two other major components – mental health promotional activities in all schools and referrals to mental health specialists for children with the most serious problems – which were not the focus of this study.
Study co-author Michael Jellinek, MD, former Chief of Child Psychiatry at MGH and creator of the Pediatric Symptoms Checklist, says, “The findings from this study have significance that goes beyond the field of psychology. The government of Chile recognizes the critical importance of education to its nation’s future and to breaking the cycle of poverty. By recognizing that good mental health is essential to learning, it has taken a place of leadership among world nations. In our two previous research collaborations with the Skills for Life team, we already had shown that mental health problems are quite common, are among the strongest predictors of poor attendance, poorer grades, and lower scores on standardized tests, and that improved mental health scores are powerful predictors of improved academic outcomes.”
Murphy adds, “The success of the Skills for Life program, including the results in our current paper, has led the government of Chile to fund a major increase in the size of the program, adding more than 400 schools during the next school year. The government was willing to work with the researchers to add the new schools in a controlled fashion, so that we can use an experimental design that will allow us to test the impact of the program in a more scientifically rigorous way. If the results of that evaluation confirm the results reported in our current paper, we will have made one of the strongest statements ever that mental health matters, not just for emotional health but for educational outcomes as well.”
Guzmán notes that The Skills for Life program is available to all schools with high poverty rates in Chile, but that schools must request it, and local school districts must contribute some funding. The program is very popular with the schools, school districts, and municipal authorities and is growing in scope as well as in size. Versions for preschoolers and middle school students have been added in recent years and are running in hundreds of additional schools. He adds that future evaluations may assess whether students who get the intervention in several different grades show greater gains than those who receive it just once. “We are also interested in following students who receive these interventions into adulthood to see how long these gains last. The program was started in the hope that it could help our country to overcome some of the social problems that hold it back, and we believe that this first phase of research shows that we are on the right track.”
Additional co-authors are Ana Maria Squicciarini, current national director of the Skills for Life program; Myriam George, of the University of Chile, one of the program’s creators and a technical advisor for more than fifteen years; Lee Baer, PhD, Katia Canenguez, PhD, and Madelaine Abel, BA, MGH Psychiatry Department; Alyssa McCarthy, Rutgers University; and Ronald C. Kessler, PhD, the McNeil Family Professor of Health Care Policy at Harvard Medical School. Murphy is an associate professor of Psychology and Jellinek is a professor of Psychiatry and Pediatrics at HMS. The Skills for Life program is funded by the JUNAEB branch of the Chilean Ministry of Education, and support for the data analysis and paper preparation was provided by the Fuss Family Fund.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $760 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine. In July 2015, MGH returned into the number one spot on the 2015-16 U.S. News & World Report list of "America's Best Hospitals."
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