Mental health difficulties are the leading cause of disease globally, with most occurring before the age of 14. The rising cases of mental health problems among children and young people (CYP) over recent years, in part attributable to the COVID-19 pandemic and widespread social isolation, subsequently presents a substantial public health concern (Racine et al., 2021; Wykes et al., 2023).

Rates of suicide among CYP further underscore the urgency of this issue. As highlighted in a review by Edwards et al. (2024), which I blogged about earlier this year, there is increasing demand for crisis services in this population, pointing to the need for effective preventive interventions. Despite the growing number of evidence-based treatments for CYP (Kieling et al., 2011; Klasen & Crombag 2013), accessibility remains a significant barrier, with many CYP facing long waiting times for treatment (Department of Health, 2015; Radez et al., 2021). Effective prevention is crucial – not only for immediate psychological and social benefits, but also for reducing the prevalence of mental health disorders in adulthood (Wykes et al., 2023).

This blog will discuss a “review of reviews” by McGovern et al. (2024) that aimed to map the field of preventive interventions, identifying promising approaches to reduce mental health problems in CYP, and providing evidence to inform practice.

Methods

This review adhered to PRISMA guidelines and was pre-registered on PROSPERO. Six databases were searched, alongside reference lists of relevant studies and contacting authors working in the field to identify unpublished work. Studies were eligible to be included if they were systematic reviews of randomised controlled trials (RCTs), quasi-experimental studies, or outcome evaluations of secondary preventive interventions for CYP (or their parents) aged 3-17 years old. No language or date restrictions were applied.

Two reviewers independently screened and evaluated studies, with discrepancies resolved by discussion or a third researcher. Data was extracted using a piloted form, with synthesis by intervention type and quality assessment using the AMSTAR 2. Reviews were not excluded based on quality, but this informed the confidence in the evidence synthesis. The majority of studies were rated as critically low (n = 23), with 12 rated as high, five as moderate, and nine as low.

Results

After screening, 54 papers reporting on 49 unique reviews were included. These reviews included between 2 to 249 unique studies (M =  34), with most (70%) being RCTs.

Reviews examined interventions that were selective (n = 22), indicated (n = 15), or a combination of both (n = 12):

• Selective interventions refer to those that target preventing mental illness in CYP at increased risk of developing mental health problems due to biological, psychological, or social risk factors.
• Indicated interventions focus on preventing mental illness in CYP who have been identified as having pre-clinical symptoms (Cho & Shin, 2013).

Selective interventions targeted CYP facing adversity, minority groups, and young mothers, while indicated interventions addressed subclinical internalising problems, externalising problems, and self-harm.

Selective interventions

• High- to moderate-confidence reviews mostly showed effectiveness for CYP facing adversity, particularly those with mentally ill parents.
• Interventions like cognitive behavioural therapy (CBT), psychoeducation, and resilience-building activities showed reductions in mental health issues, including depressive symptoms and the incidence of internalising disorders.
• Creative arts and family therapy also showed promising outcomes.
• However, one review found no significant difference in Post-Traumatic Stress Disorder (PTSD), depression, or anxiety for CYP in humanitarian crises.
• Moderate evidence from one review supported suicide prevention interventions in indigenous adolescents, though effects on ideation or attempts were not assessed.
• Low- to critically-low-confidence reviews reported mixed evidence.

Indicated interventions

• High-confidence reviews indicated effectiveness in reducing externalising problems through school-based social skills and resilience training, showing small effects post-intervention and at 12-month follow-ups.
• CBT was effective for subclinical internalising problems, reducing depression post-intervention, and at short-term follow-ups (e.g., 6 months), and anxiety in short-term follow-ups.
• One review found that dialectical behaviour therapy (DBT) showed effectiveness in reducing self-harm repetition.
• Low- and critically-low-confidence reviews presented mixed evidence on various indicated interventions, including parenting programs and psychosocial approaches, with some effectiveness in reducing depression and anxiety.

Finally, high- or moderate-confidence reviews of combined secondary interventions generally found them to be effective in reducing mental health problems such as conduct disorder, depression, anxiety, and PTSD. However, low- and critically-low-confidence reviews often reported small effects for externalising and internalising problems, with some exceptions showing larger reductions in anxiety.

Conclusions

This systematic review of reviews found a range of evidence supporting both selective and indicated interventions for at-risk CYP across various populations and settings. Selective interventions, particularly for CYP who experienced adversity, showed the strongest evidence of effectiveness. Effective approaches included CBT, psychoeducation and family therapy, with a focus on risk reduction and enhancing resilience. The evidence for PTSD and self-harm specific interventions was limited.

These findings highlight the importance of preventative interventions for CYP facing adversity and suggest that incorporating resilience building and risk reduction could improve mental health outcomes for those at risk of future difficulties.

Strengths and limitations

This review engages with a broad international literature mapping a wide range of preventive interventions, which allows for a more robust synthesis of findings and increases the likelihood of identifying best practice across different contexts. This can help to provide recommendations for policy and practice that are grounded in evidence. However, despite the wide scope of this work, there were few reviews included that examined interventions trialled in low-and-middle-income countries (LMICs). As LMICs are home to approximately 90% of the world’s CYP, who are at increased risk of mental health difficulties due to social disadvantage, poverty, and adversity (Riberio et al., 2023), they are an important population to capture. This lack of evidence suggests that there is a lot we still do not know.

Rigorous methods were used to ensure the reliability of the results; however, since the included reviews generally combined estimates from various preventive interventions, it was challenging for this review of reviews to confidently identify which interventions were the most effective. This means that while this review is able to provide an accessible overview of current evidence, addressing multiple sub-populations of CYP in a variety of contexts, it has not been able to pool the effects of different interventions in meta-analysis, limiting its conclusive ability.

That said, it is important not to compare apples and oranges. This review of reviews includes findings from studies with broad age ranges, variations in the intensity and duration of interventions, and differences in comparison conditions. Combining these outcomes may lead to misleading conclusions and inaccurate generalisations which could result in less effective implementation of these interventions. Further, conducting a review of reviews has meant that some individual studies are reported in multiple reviews. Including the same individual studies in multiple reviews can lead to double counting of evidence, skewing the overall conclusions and potentially overstating the effectiveness or impact of certain interventions.

Implications for practice

The findings from this review of reviews highlights that effective preventive interventions often combine multiple components focused on risk reduction and resilience enhancement across behavioural, interpersonal, cognitive, and emotional domains. A holistic approach to mental health in CYP is essential because all these domains are deeply interconnected, with each influencing the others. For example, improvements in emotional regulation (emotional) can reduce impulsive behaviours (behavioural), which in turn can strengthen relationships with peers and family (interpersonal). Similarly, fostering positive thinking and problem-solving skills (cognitive) can help CYP manage stress and cope with challenges more effectively, reducing the likelihood of emotional distress. These interactions mean that addressing just one domain in isolation may not be sufficient for long-term mental health improvements, while a comprehensive approach that targets all domains creates a more supportive and resilient foundation for mental well-being.

The identification of promising selective interventions may negate the need for individual risk identification, because these interventions are designed to target specific groups of CYP who share common risk factors, rather than relying on a detailed assessment of individual risks. This approach allows for more efficient and effective allocation of resources, as interventions can be implemented at a population level to support those at risk without the necessity of assessing everyone’s unique circumstances. In contrast, the identification of promising indicated interventions allows for targeted support for CYP who are already exhibiting early signs of mental health difficulties or who are at high risk of developing such issues. The benefit of indicated interventions lies in their proactive nature; by addressing issues at an early stage, they can prevent the escalation of mental health problems and improve overall functioning and well-being. This targeted strategy can also enhance resource efficiency, as it focuses efforts on those who are most likely to benefit from intervention.

During my time working in Tier 4 Inpatient Child and Adolescent Mental Health Services (CAMHS), I cared for CYP in crisis who were unable to manage their mental health in the community. I frequently heard about the barriers they and their families faced in accessing appropriate support, often noticing changes in behaviour and vulnerabilities long before hospitalisation. The restrictive nature of inpatient care and separation from their social environment highlighted to me the need for preventive interventions. This review shows promising progress in this area, offering hope that CYP and their families can receive community-based support to manage their mental well-being and prevent future illness and crises

Recommendations for implementation

• Prioritise early intervention for CYP who have experienced adversity to prevent the development of mental health problems.
• Providing comprehensive training for practitioners and stakeholders ensures that they have the necessary skills and knowledge to effectively implement interventions.
• Building local capacity also fosters ownership and commitment to the initiatives.
• Embedding interventions within existing mental health services or educational frameworks helps to ensure ongoing support and reduces the burden of establishing entirely new systems. This integration also promotes continuity of care for CYP.
• Interventions should be designed to be adaptable to different settings, cultures, and populations, allowing them to be relevant and effective across diverse communities. This flexibility facilitates wider adoption and integration into existing systems.
• Securing sustainable funding sources is essential for the long-term viability of interventions.

Statement of interests

None.

Links

Primary paper

McGovern, R., Balogun-Katung, A., Artis, B., Bareham, B., Spencer, L., Alderson, H., … & Kaner, E. (2024). The effectiveness of preventative interventions to reduce mental health problems in at-risk children and young people: a systematic review of reviews. Journal of Prevention, 1-34.

Other references

Cumber, B. (2024). Are crisis responses for children and young people effective? The Mental Elf.

Cho, S. M., & Shin, Y. M. (2013). The promotion of mental health and the prevention of mental health problems in child and adolescent. Korean Journal of Pediatrics, 56(11), 459–464.

Edwards, D., Carrier, J., Csontos, J., Evans, N., Elliott, M., Gillen, E., … & Williams, L. (2024). Crisis responses for children and young people–a systematic review of effectiveness, experiences and service organisation (CAMH‐Crisis). Child and Adolescent Mental Health, 29(1), 70-83.

NHS England (2015). Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing. Department of Health.

Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., … & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515-1525.

Klasen, H., & Crombag, A. C. (2013). What works where? A systematic review of child and adolescent mental health interventions for low and middle income countries. Social Psychiatry and Psychiatric Epidemiology, 48, 595-611.

Racine, N., McArthur, B. A., Cooke, J. E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA Pediatrics, 175(11), 1142-1150.

Radez, J., Reardon, T., Creswell, C., Orchard, F., & Waite, P. (2021). Adolescents’ perceived barriers and facilitators to seeking and accessing professional help for anxiety and depressive disorders: a qualitative interview study. European Child & Adolescent Psychiatry, 1-17.

Ribeiro, W. S., Grande, A. J., Hoffmann, M. S., Ziebold, C., McDaid, D., Fry, A., Peixoto, C., Miranda, C., King, D., Tomasi, C. D., Faustino, C., Leone, S., Moraes, S., Schäfer, A. A., Alves, V., Rosa, M. I., & Evans-Lacko, S. (2023). A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries. Comprehensive Psychiatry, 121, 152358.

Wykes, T., Bell, A., Carr, S., Coldham, T., Gilbody, S., Hotopf, M., … Creswell, C. (2021). Shared goals for mental health research: what, why and when for the 2020s. Journal of Mental Health, 32(6), 997–1005.

Photo credits

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