Adolescent Mental Health ProgramComponents and Behavior RiskReduction: A Meta-analysisSarah Skeen, PhD,a Christina A. Laurenzi, MSc,a Sarah L. Gordon, MA,a Stefani du Toit, MA,a Mark Tomlinson, PhD,a,b

Tarun Dua, MD,c Alexandra Fleischmann, PhD,c Kid Kohl, PhD,c David Ross, PhD,c Chiara Servili, PhD,c Amanda S. Brand, PhD,a

Nicholas Dowdall, MSc,d Crick Lund, PhD,e Claire van der Westhuizen, PhD,e Liliana Carvajal-Aguirre, MSc,f

Cristina Eriksson de Carvalho, PhD,g G.J. Melendez-Torres, DPhilh

abstractCONTEXT: Although adolescent mental health interventions are widely implemented, littleconsensus exists about elements comprising successful models.

OBJECTIVE: We aimed to identify effective program components of interventions to promotemental health and prevent mental disorders and risk behaviors during adolescence and tomatch these components across these key health outcomes to inform future multicomponentintervention development.

DATA SOURCES: A total of 14 600 records were identified, and 158 studies were included.

STUDY SELECTION: Studies included universally delivered psychosocial interventions administeredto adolescents ages 10 to 19. We included studies published between 2000 and 2018, usingPubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstractsdatabases. We included randomized controlled, cluster randomized controlled, factorial, andcrossover trials. Outcomes included positive mental health, depressive and anxioussymptomatology, violence perpetration and bullying, and alcohol and other substance use.

DATA EXTRACTION: Data were extracted by 3 researchers who identified core components andrelevant outcomes. Interventions were separated by modality; data were analyzed by usinga robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects.

RESULTS: Universally delivered interventions can improve adolescent mental health and reducerisk behavior. Of 7 components with consistent signals of effectiveness, 3 had significanteffects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol anddrug education).

LIMITATIONS: Most included studies were from high-income settings, limiting the applicability ofthese findings to low- and middle-income countries. Our sample included only trials.

CONCLUSIONS: Three program components emerged as consistently effective across differentoutcomes, providing a basis for developing future multioutcome intervention programs.

aInstitute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; bSchool of Nursing andMidwifery, Queens University, Belfast, United Kingdom; cWorld Health Organization, Geneva, Switzerland; dDepartment of Social Policy and Interventions, Oxford University, Oxford, UnitedKingdom; eAlan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; fData and Analytics Section, Divisionof Data Research and Policy and gDepartment of Maternal, Newborn, Child and Adolescent Health, United Nations Children’s Fund, New York, New York; and hCentre for the Development andEvaluation of Complex Interventions for Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, United Kingdom

To cite: Skeen S, Laurenzi CA, Gordon SL, et al. Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis. Pediatrics. 2019;144(2):e20183488

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Globally, many adolescents live inenvironments in which poverty,conflict, or abuse is common, placingthem at risk for developing mentaldisorders1 or engaging in co-occurring risky behaviors such assubstance use and physical violence.2

These behaviors have implications foradolescent health and developmentand contribute to the disease burdenin this age group.3 Adolescence is alsoa time when chronic mental disordersmay develop,4 which can placeadolescents at further risk forunhealthy behaviors, injuries, anddiseases and contribute to poorphysical and mental health in lateryears.5 Young people suffering frommental health problems have moredifficulty forming interpersonalrelationships, performing in school,and contributing productively inwork environments.1

However, adolescence is also a time ofrapid physical, social, andpsychological development, and asa result, it offers multipleopportunities for health promotionand disease prevention.6 Authors ofprevious systematic reviews oninterventions to promote mentalhealth and prevent mental disordersand risk behaviors duringadolescence have concluded thatpsychosocial interventions can beeffective in improving youth mentalhealth.7,8 These interventions canprovide foundational skills for thepromotion of healthy behaviors andprevention of risk behaviors, such asviolence (including bullying), tobaccouse, and alcohol and substance abuse,through further generalizing behaviorchange improvements to otherdomains.9 Authors of past reviewshave tended to focus on single-issueinterventions and outcomes only,such as delaying alcohol use orpreventing depression.10–12 In real-life settings, single-issueinterventions are more likely to be“crowded out” by other newprograms when funding or policypriorities shift; this approach also

ignores the fact that risk andprotective factors for health anddevelopment often overlap.9,13

The process of synthesizing evidencefor programming purposes shouldthus be reframed; rather thandevoting time to developing single-issue interventions, more attentionshould be paid to identifying commonfeatures of proven interventions foruse across multiple outcome areas.The use of key component profileshas been used in process evaluationand best practices research, includingin mental health case management.14

This strategy improves cost-effectiveness, expands anintervention’s reach andsustainability, and may also cullineffective or harmful components. Itis also of particular interest for low-resource settings in which multi-outcome interventions may be moreattractive to policymakers because oftheir potential to have a broad effectfor the cost of a single program.15

“Helping Adolescents Thrive” isa World Health Organization andUnited Nations Children’s Fundinitiative used to develop a package ofevidence-based psychologicalinterventions to promote adolescentmental health and prevent mentaldisorders and risk behaviors amongadolescents. As a part of this project,we conducted a systematic review,meta-analysis, and programcomponents analysis of universallydelivered interventions that soughtthese aims. Our purpose of this reviewwas to inform the development of theintervention package. Specifically, wewanted to identify content-relatedfeatures of programs (known asprogram or practice components) thatconsistently predict larger effect sizesin these programs across a range ofoutcomes.

METHODS

A protocol for this systematic reviewwas agreed with the World HealthOrganization as the version of record

(see Supplemental Information). Wepresent findings relating to universalinterventions only in this article(programs that are targeted at thewhole adolescent population and aredesigned to benefit everyone, notonly specific at-risk groups).

Search Strategy and SelectionCriteria

We included (1) randomizedcontrolled trials (RCTs) ofpsychosocial interventions (2) withadolescent participants between theages of 10 to 19 (3) in which trialinterventions had the primary orsecondary aims of promoting mentalhealth or preventing mentaldisorders, reducing risk behaviors, orreducing self-harm and suicide;additionally, (4) the programs wereaimed at the whole adolescentpopulation and were designed tobenefit everyone regardless of settingor delivery and (5) publishedbetween January 2000 and February2018 in any language. Studies inwhich authors compared outcomesbetween groups who received anintervention and those who receivedusual or no care and/or those whoreceived a different intervention wereincluded. We included studies if themean age was between 10 and19 years or .50% of the participantswere between 10 and 19 years old.Outcomes included positive mentalhealth (mental well-being, resilience,coping, emotional regulation),depressive and anxioussymptomatology, violenceperpetration and bullying, andalcohol and other substance use. Weincluded different time points andcoded outcomes according to short(,2 months after interventioncompletion), medium (2–6 months),and long-term (.6 months).

We searched Medline, PsycINFO,Scopus, Embase, and Applied SocialSciences Index Abstracts andfollowed references of reviews.Duplicate abstracts were removed,and the remaining abstracts were

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assessed against inclusion criteria by2 independent reviewers. Anydisagreements were resolved bydiscussion between the 2 reviewersor resolved by the arbitration ofa third reviewer. Subsequently, full-text reports were accessed andassessed. Pairs of reviewers workingindependently completed thisscreening process. Data wereextracted by using a standardizedform and included trialcharacteristics, setting, sampling,population characteristics,intervention details, outcome

measures, study quality (assessed byusing the Cochrane risk-of-bias tool),and treatment effects. In addition,each intervention was codedaccording to the presence of specificpractice components. Details weregathered directly from the studypublications and directly fromintervention manuals when available.We relied on authors’ explicitdescription of components wheneverpossible; for example, the presence of“stress management” would not beinferred from a coping skillsintervention unless the authors

discussed stress specifically. In manycases, authors expounded on programelements in tables or figures. Programcontent components were codedaccording to a system based on thework of Boustani et al16 in which thePracticeWise Clinical CodingSystem17 was used to identifycommon practices across a range ofprevention programs. We also addedother program components relatingto theoretically relevant methods.18

Finally, on the basis of thePracticeWise recommendations andas implemented by Brown et al19 in

TABLE 1 Included Components

Component Definition

Activity monitoring and schedulinga Practical approach to monitor activities and/or scheduling; completion of an activity chart to aid inmotivation and organization

Alcohol and/or drug educationa Specific knowledge and/or education about the use of or effects of drugs and/or alcohol ondevelopment, lifestyle, including harm minimization approaches, and beliefs and/or perceptionsabout drugs/alcohol

Anger managementb Skills to manage anger and/or angry feelings; control techniquesAssertivenessb Techniques to increase confidence, standing up for oneself, standing ground, and/or holding

a positionBehavioral activationc Therapy technique of approaching activities that one is avoiding and analyzing how cognitive

processes play a partCivic and/or social responsibilityb Engagement with community and/or community-based institution such as school, church, or

political system; encouragement to involve oneself; responsibility to others (bystanderintervention)

Cognitive restructuringb Identification and replacement of unhelpful thoughts with more helpful thoughtsCommunication skillsb Improvement of ways in which participants use words; nonverbal styles of communication,

expression of feelings or beliefs, and engagement with othersConflict resolutiona Skills to resolve conflict or negotiation between $2 peopleCoping skillsb Methods a person uses to deal with stressful situations; grief managementDecision makinga Ability to review information and select a choiceEmotional regulationc Ability to effectively manage and respond to an emotional experienceGoal settingb Identification of a goal; establishment of measurable ways to accomplish and timelineInsight buildingb Development of internal insights, reflection, probing a better understanding of personal motivations

(guided); self-awarenessInterpersonal relationships and/or skillsa Skills to develop or improved close, strong relationships between $2 peopleMental health literacya Knowledge and beliefs about mental disorders; reducing stigma and increasing awarenessMindfulnessc Psychological process of bringing one’s attention to experiences occurring in the present moment,

which can be developed through the practice of meditation and other trainingProblem solvingb Process of finding, and perhaps acting on, a solution to a challenge or difficult problemRelaxationb Techniques for freeing oneself from tension and anxiety; learning how to remove oneself from

a state of agitationResisting drug/alcohol-related peer pressurea Specific refusal skills or self-efficacy as it relates directly to drug or alcohol use or pressure to useSelf-efficacyb One’s own beliefs and capacity to execute behaviors necessary to produce a specific performance;

acting on knowledge learnedSelf-monitoringb Observation and regulation of one’s own mood and behavior in a social setting; diary keeping and/or

journalingSocial skillsb Competence in communicating, interacting, and engaging with othersStress managementa A large range of techniques to control levels of stress, especially chronic stress that impedes

everyday functioningSupport networkingb Identification of a group of people who can provide emotional and practical help to manage difficult

situations

a Iteratively added by coding team.b From Boustani et al.16c From Singla et al.25

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a similar activity, we recorded otherfrequently occurring components asfree text and ultimately integratedthem as new codes into theframework (Table 1). Some of theseincluded decision-making,20 conflictresolution,21 mindfulness,22,23 andalcohol and drug education.24

Data Analysis

For reporting and analysis, wecategorized all universally deliveredprograms into face-to-face, digital, orcombined modality interventions.Face-to-face interventions consistedof all interventions delivered in

schools, communities, or healthcenters; digital and combinedmodality interventions consisted ofinterventions that were solelydigitally delivered content or digitalcontent in combination with othermodes of delivery.

Effect estimates from includedstudies were converted tostandardized mean differences byusing available published formulas.26

A common problem in meta-analysesof complex interventions is that studyauthors report multiple effectestimates from the same domain (ie,conceptually exchangeable and thus

equally valid) in respect to anoutcome and often report outcomesfrom multiple time points. To addressthis, we used a robust varianceestimation meta-analysis model27 toinclude all relevant information fromincluded studies. We estimated allmodels using random effects, givenhigh anticipated levels of statisticalheterogeneity and an intercorrelationparameter of 0.8, which is standard,to estimate how closely effectestimates within a study are related.Given the number and diversity ofcomponents we sought to analyze, weestimated a series of single-predictormeta-regression models. Predictorswere entered into models as thestudy-level mean of a component. Instandard 2-arm trials and trials inwhich components were binary, thisvariable took on the value of 1 or 0. Inmultiarm trials in which the $2active arms differed as to thepresence of a component, the variabletook on the value of the proportion ofeffect estimates with a specificcomponent. We estimated all modelsfirst with effect estimatescorresponding to #2 months offollow-up and then with effectestimates over all follow-up times.We noted when models could notprovide usable evidence because ofmodel instability. We did not formallytest publication bias given that thesetests are not understood in thecontext of robust variance estimationmeta-analysis. In assessingdifferences in effect sizes, we usedstandard thresholds of 0.2 for smalleffect size, 0.5 for medium effectsize, and 0.8 for large effectsize.28

RESULTS

We identified 14 600 records throughdatabase searches and handsearching, of which 158 were suitableand reported data suitable forcomponents analysis (Fig 1).

The characteristics of studies thatmet the inclusion criteria and

FIGURE 1Flowchart. Articles in which authors reported on the same study and sample were combined foranalysis (thus, n 5 492 decreased to 473). a Exclusion reasons were wrong age (n 5 59), wrongstudy design (n 5 23), wrong outcome (n 5 10), wrong intervention (n 5 21), wrong population(n 5 18), pre-2000 study (n 5 1), could not locate (n 5 6), wrong publication (ie, conferenceproceeding; n 5 70).

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contributed data to the componentsanalysis are summarized in Table 2,and all included studies are listed inSupplemental Information 2. Theaverage intervention duration was13.88 hours for face-to-faceinterventions and 6.05 hours fordigital interventions (seeSupplemental Information 4 and 5).The average number of componentsper intervention was 5.4 for face-to-face interventions and 5.9 for digital

interventions (further details inSupplemental Information 4and 5).

In general, risk of bias was low acrossmost categories, with the exception ofallocation concealment and randomsequence generation (see Fig 2 andSupplemental Information 3 for fulldetails). In the majority of studies, itwas unclear who had beenresponsible for randomization as

well as how the randomizationsequence was generated. It was alsounclear if this sequence wasprotected sufficiently to prevent theresearch team from predicting thenext treatment allocation during theprocess. Furthermore, in manystudies, blinding of participants andoutcome assessment was notpossible because of the studydesign, particularly in school-basedsettings in which whole schools orspecific classes were allocated tothe intervention status. Outcomedata assessment largely presenteda low risk of bias, but approximatelyone-third of studies had unclearrisk of attrition or other biases.Almost 90% of studies had a lowrisk of bias for selectivereporting.

The overall effect sizes ofuniversally delivered interventionson each of the study outcomes arereported in Table 3. Self-harm andsuicide were not included in theanalyses reported here becausethere were only 2 universallydelivered interventions located inwhich these outcomes werereported. For face-to-faceinterventions in the short-term,there were significant differencesbetween intervention and controlgroups for positive mental healthand depression and anxietysymptoms. Across all time points,there were significant differencesbetween intervention and controlgroups for positive mental health,depression and anxiety symptoms,and violence, aggression, andbullying. For digital or combinedmodality interventions, onlydepression and anxiety outcomesimproved in the short-term, but thiswas not evident across all timepoints. For all time points, therewere significant differencesbetween intervention and controlfor positive mental health andsubstance use. All overall significanteffect sizes were small to moderateand indicated beneficial effects of

TABLE 2 Descriptors of the Included Universal Interventions

Descriptor Face-to-face Prevalence (n 5129 Studies)

Digital and Combined Prevalence (n 529 Studies)

Design, n (%)RCT 47 (36.4) 14 (46.7)Cluster RCT 80 (62.0) 15 (53.3)Crossover RCT 2 (1.6) 0 (0.0)

High-income setting, n (%) 115 (89.1) 28 (96.7)United States 72 (55.8) 13 (46.7)Australia 16 (12.4) 9 (30.0)

LMIC, n (%) 14 (10.9) 1 (3.3)Age in categories, n (%)10–14 y 90 (69.8) 17 (56.7)15–19 y 24 (18.6) 9 (33.3)Across both categories 12 (9.3) 3 (10.0)Missing data 3 (2.3) 0 (0.0)

Setting, n (%)School 111 (86.0) N/ACommunity 8 (6.2) N/AMultisetting 5 (3.9) N/AHealth center 4 (3.1) N/AUniversity 1 (0.8) N/ADigital only N/A 20 (70.0)Combined digital N/A 9 (30.0)

Sexn 113 28Girls, % 51.8 55.9Boys, % 48.4 44.1

Sample size, average (SD) 1415 (2341.86) 1650 (2111.94)

N/A, not applicable.

FIGURE 2Risk of bias across all studies.

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interventions. There were nodifferences for face-to-faceinterventions for substance use atany time point or for violence,aggression, and bullying in theshort-term. There were nodifferences for digital and combinedmodality interventions for short-term positive mental health andsubstance use outcomes, depressionand anxiety beyond the short-term, or for aggression, violence,and bullying across any timepoint.

Seven intervention componentspredicted only positive effects, that is,their presence was associated withmore successful programs (see Tables4 and 5). These were interpersonalskills, emotional regulation, alcoholand drug education, mindfulness,problem solving, assertivenesstraining, and stress management. Thepresence of interpersonal skills wasmost consistently associated withlarger effect sizes, yielding improvedeffects for positive mental health,depression and anxiety prevention,and prevention of substance use.Emotional regulation was associatedwith greater effectiveness inimproving positive mental health andgreater reductions in depressive andanxious symptomatology. Alcohol anddrug education predicted positiveoutcomes for non–alcohol- andnon–drug-related outcomes, namely,positive mental health in face-to-face

interventions and aggression indigital interventions. The remainingcomponents were associated withlarger effect sizes in 1 outcomecategory only. Mindfulness wasassociated with a decrease in anxietyand depression symptoms in face-to-face interventions. Problem solvingwas associated with a decrease indepression and anxiety symptoms indigital and combined interventions.Assertiveness and stress managementpredicted larger effect sizes for theprevention of substance use in digitalinterventions. See SupplementalInformation 2 for full details of thepresence of program components ininterventions.

Six practice components revealedmixed results across the differentoutcomes; these components wereconflict resolution, coping skills, goalsetting, relaxation, skills to resist peerpressure, and self-efficacy training. Inface-to-face interventions, conflictresolution predicted larger effects forsubstance use but smaller effects fordepression and anxiety symptoms.Coping skills content did not predictany outcomes for face-to-faceinterventions but predicteddiminished effectiveness for positivemental health and strongereffectiveness for substance use fordigital interventions. Goal setting waspredictive of smaller program effectsfor depression and anxiety in face-to-face interventions but larger effects

for digital substance useinterventions. Relaxation wasassociated with smaller effect sizesfor digital positive mental healthoutcomes but stronger effectivenessfor substance use. Skills toresist peer pressure predictedlarger effects for violence outcomein digital interventions but smallereffects for aggression and positivemental health outcomes in face-to-face interventions. Fordepression and anxiety symptoms,self-efficacy predicted smaller effectsizes for face-to-face interventionsbut larger effects for digitalinterventions.

Across all meta-regressions, 6components were associated witheither attenuated effectiveness orminimal difference in effectiveness,depending on the outcome; thesecomponents were activity monitoringand scheduling, anger management,civic responsibility, communicationskills, decision-making, and insightbuilding. Communication skills andactivity monitoring and schedulingwere associated with smaller effectsizes for depression and anxietyoutcomes in face-to-faceinterventions. Digital and combinedinterventions that included civicresponsibility were less effective atreducing depressive and anxioussymptomatology. In face-to-faceinterventions, the inclusion ofdecision-making activities wasassociated with smaller effect sizes onpositive mental health and depressiveand anxious symptomatology. Insightbuilding predicted a smaller effectsize for positive mental health whenincluded in digital and combinedinterventions.

A final set of practice componentsthat did not have a clear relationshipto effectiveness in either directionincluded cognitive restructuring,mental health literacy, self-monitoring, social skills, supportnetworking, and behavioralactivation.

TABLE 3 Overall Effect Sizes per Outcome

,2 mo, ES (95% CI) All Time Points, ES (95% CI)

Positive mental healthFace-to-face 0.247 (0.100 to 0.395) 0.257 (0.097 to 0.416)Digital and combined 0.175 (20.034 to 0.383) 0.197 (0.016 to 0.379)

Depression and anxiety symptomsFace-to-face 20.104 (20.197 to 20.01) 20.088 (20.151 to 20.025)Digital and combined 20.094 (20.183 to 20.004) 20.054 (20.181 to 0.074)

Violence, aggression, and bullyingFace-to-face 20.138 (20.235 to 0.049) 20.294 (20.564 to 20.024)Digital and combined 20.073 (20.242 to 0.095) 20.075 (20.249 to 0.099)

Substance useFace-to-face 0.017 (20.085 to 0.119) 20.04 (20.117 to 0.037)Digital and combined 20.048 (20.16 to 0.064) 20.114 (20.199 to 20.029)

For positive mental health, a positive effect size denotes a beneficial effect. For all other outcomes, a negative effect sizedenotes a beneficial effect. CI, confidence interval; ES, effect size.

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TABLE4Face-to-face

Program

Component

Effect

SizesperOutcom

eArea

Program

Components

Prom

otionof

PositiveMentalHealth

Preventionof

AnxiousandDepressive

Symptom

ology

Preventionof

Violence,Aggression,and

Bullying

Preventionof

SubstanceUse

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

Activity

monitoring

and

scheduling

20.264(2

1.061to

0.534)

a20.237(2

1.172to

0.644)

a0.162(0.061

to0.263)

0.123(0.057

to0.19)

——

——

Alcoholand/or

drug

education

0.139(2

0.015to

0.293)

20.200(2

0.751to

0.351)

a—

—0.087(2

0.11

to0.284)

0.357(2

0.263to

0.977)

a20.032(2

0.234to

0.169)

20.025(2

0.181to

0.131)

Angermanagem

ent

0.155(2

0.015to

0.293)

20.038(2

0.400to

0.324)

0.062(2

0.317to

0.44)a

0.063(2

0.098to

0.224)

0.216(2

0.075to

0.508)

0.409(0.003

to0.789)

0.077(2

0.032to

0.185)

20.093(2

0.735to

0.548)

a

Assertiveness

0.100(2

0.356to

0.555)

0.071(2

0.345to

0.486)

0.125(2

0.083to

0.333)

20.009(2

0.167to

0.149)

20.263(2

1.05

to0.525)

20.371(2

1.242to

0.5)

0.068(2

0.203to

0.339)

a20.078(2

0.221to

0.066)

Behavioral

activation

20.199(1.064

to0.667)

a20.203(2

0.62

to0.214)

a—

—0.114(2

0.497to

0.725)

a0.296(2

0.225to

0.313)

a—

—

Civicresponsibility

0.093(2

0.515to

0.701)

20.005(2

0.439to

0.428)

0.335(2

1.793to

2.463)

a0.284(2

1.99

to2.558)

a20.189(2

1.197to

0.32)a

0.076(2

0.424to

0.576)

—20.069(2

0.552to

0.415)

a

Cognitive

restructuring

0.174(2

0.193to

0.542)

0.037(2

0.287to

0.361)

20.033(2

0.227to

0.161)

20.056(2

0.191to

0.08)

20.184(2

0.871to

0.503)

20.068(2

0.802to

0665)

0.166(2

0.704to

1.036)

a0.168(2

0.346to

0.682)

Communicationskills

0.026(2

0.367to

0.418)

20.041(2

0.409to

0.326)

0.190(2

0.006to

0.387)

0.111(2

0.015to

0.238)

20.012(2

0.562to

0.538)

20.161(2

0.856to

0.534)

0.133(2

0.097to

0.363)

0.006(2

0.125to

0.136)

Conflictresolution

20.286(2

0.871to

0.300)

20.257(2

0.707to

0.194)

0.179(2

0.056to

0.413)

0.147(0.015

to0.279)

0.211(2

0.104to

0.525)

0.08

(20.578to

0.737)

20.127(2

0.234to

20.021)

20.066(2

0.384to

0.253)

Coping

skills

0.001(2

0.326to

0.328)

20.115(2

0.428to

0.198)

0.134(2

0.047to

0.315)

0.049(2

0.081to

0.179)

0.083(2

0.300to

0.466)

20.163(2

0.800to

0.473)

0.166(2

0.704to

1.036)

0.073(2

0.150to

0.295)

Decision-making

20.274(2

0.557to

0.009)

20.207(2

0.465to

0.051)

0.263(0.093

to0.433)

0.116(2

0.031to

0.263)

0.058(2

0.361to

0.478)

0.306(2

0.090to

0.703)

20.068(2

0.283to

0.148)

20.064(2

0.201to

0.072)

Emotionalregulation

0.33

(20.035to

0.694)

0.123(2

0.201to

0.447)

20.087(2

0.293to

0.124)

20.062(2

0.199to

0.075)

20.250(2

0.800to

0.300)

20.305(2

0.887to

0.277)

0.174(2

0.306to

0.655)

0.051(2

0.421to

0.524)

Goal

setting

0.123(2

0.365to

0.61)

0.027(2

0.376to

0.431)

0.194(2

0.032to

0.421)

0.175(0.025

to0.326)

20.015(2

0.316to

0.335)

a0.274(2

0.271to

0.818)

0.185(2

0.248to

0.617)

0.099(2

0.105to

0.304)

Insightbuilding

0.142(2

0.269to

0.553)

0.067(2

0.265to

0.399)

0.157(2

0.04

to0.353)

0.070(2

0.074to

0.215)

20.205(2

1.131to

0.72)

20.074(2

0.791to

0.646)

20.023(2

0.238to

0.192)

a0.040(2

0.111to

0.191)

Interpersonalrelationships

and/or

skills

0.048(2

0.354to

0.45)

0.143(2

0.256to

0.542)

0.070(2

0.169to

0.309)

0.066(2

0.074to

0.206)

0.044(2

0.377to

0.465)

20.175(2

0.716to

0.366)

20.160(2

0.344to

0.024)

20.190(2

0.313to

20.067)

Mentalhealth

literacy

20.048(2

0.650to

0.555)

20.071(2

0.659to

0.517)

20.029(2

0.521to

0.463)

0.005(2

0.228to

0.237)

0.106(2

1.247to

1.459)

0.343(2

0.331to

1.517)

—20.036(2

1.056to

1.434)

Mindfulness

0.157(2

0.236to

0.550)

0.149(2

0.266to

0.564)

20.272(2

0.481to

20.063)

20.219(2

0.399to

20.040)

20.529(2

1.599to

0.542)

20.428(2

1.692to

0.836)

20.041(2

0.149to

0.068)

—

Problem

solving

0.059(2

0.263to

0.381)

20.055(2

0.390to

0.280)

0.115(2

0.076to

0.305)

0.061(2

0.074to

0.195)

0.209(2

0.154to

0.572)

0.136(2

0.422to

0.694)

0.349(2

0.134to

0.832)

20.019(2

0.242to

0.205)

Relaxation

0.226(2

0.161to

0.614)

0.147(2

0.219to

0.513)

20.081(2

0.278to

0.117)

20.101(2

0.245to

0.043)

20.818(2

3.047to

1.412)

20.758(2

2.387to

0.871)

20.041(2

0.149to

0.068)

—

Resistingpeer

pressure

20.201(2

0.881to

0.479)

20.293(0.610

to0.025)

—0.193(2

0.358to

0.744)

—0.459(2

0.022to

0.939)

0.010(2

0.212to

0.232)

20.059(2

0.190to

0.073)

Self-efficacy

0.037(2

0.402to

0.477)

0.434(2

0.387to

1.255)

0.251(0.089

to0.412)

0.141(0.003

to0.278)

0.150(2

1.057to

1.356)

20.622(2

2.803to

1.559)

0.137(2

0.206to

0.480)

0.155(2

0.044to

0.354)

PEDIATRICS Volume 144, number 2, August 2019 7 by guest on December 21, 2020www.aappublications.org/newsDownloaded from

DISCUSSION

This is the first global review of activecomponents present in interventionsthat are aimed to improve adolescenthealth across a range of interrelatedmental health outcomes. With theresults of this review, we indicate, first,that universally deliveredinterventions can improve adolescentmental health and reduce riskbehavior and, second, that there areseveral content-related programcomponents that are associated withlarger or smaller effect sizes. Of thesecomponents, however, only 3predicted positive effects acrossmultiple outcomes: interpersonalskills training, emotional regulation,and alcohol and drug education. Thisfinding reflects those in a review bySingla et al25 which also found thatinterpersonal and emotional elementshad the strongest associations withoverall effectiveness across mentalhealth interventions delivered by layhealth workers in low- and middle-income countries (LMICs).

Developing skills to improveinterpersonal relationships ishighly relevant for improvingadolescent mental health outcomes,and our findings indicate thatincluding these skills in multioutcomeinterventions designed to promotemental health and prevent mentaldisorders and risk behaviors isa valuable strategy. Previous researchhas revealed that poor-qualityrelationships consistently predict poormental health outcomes foradolescents,29,30 whereas positiverelationships are associated withbetter mental health outcomes.31 Inthis review, intervention contentcommonly included verbal andnonverbal communication skills16 andwas often combined with broadersocial skills training focusing on howan individual engages in a socialsetting or larger group.32–34

Activities used to develop emotionalregulation skills were common ininterventions that were aimed toTA

BLE4

Continued

Program

Components

Prom

otionof

PositiveMentalHealth

Preventionof

AnxiousandDepressive

Symptom

ology

Preventionof

Violence,Aggression,and

Bullying

Preventionof

SubstanceUse

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

Self-monitoring

20.126(2

0.473to

0.222)

20.160(2

0.479to

0.159)

20.040(2

0.224to

0.144)

20.046(2

0.018to

0.088)

20.298(2

1.000to

0.404)

20.286(2

1.180to

0.609)

20.092(2

0.773to

0.590)

0.230(2

0.488to

0·948)

Social

skills

20.201(2

0.582to

0.181)

0.132(2

0.451to

0.714)

0.138(2

0.078to

0.354)

0.079(2

0.079to

0.237)

20.157(2

0.788to

0.473)

20.352(2

1.269to

0.556)

20.138(2

0.413to

0.141)

20.015(2

0.243to

0.214)

Stress

managem

ent

20.039(0.368

to0.289)

20.071(2

0.375to

0.234)

20.090(2

0.290to

0.111)

20.084(2

0.250to

0.082)

0.198(2

0.159to

0.555)

0.344(2

0.080to

0.767)

20.041(2

0.149to

0.068)

0.065(2

0.524to

0.654)

Supportnetworking

0.015(2

0.340to

0.369)

20.113(0.437

to0.210)

20.027(2

0.258to

0.203)

0.010(2

0.148to

0.168)

0.092(2

0.271to

0.456)

0.307(2

0.144to

0.757)

20.012(2

0.883to

0.86)

0.019(2

0.149to

0.187)

Forpositivementalh

ealth,a

positiveeffectsize

denotesabeneficialeffect.For

allother

outcom

es,a

negativeeffectsize

denotesabeneficialeffect.CI,confidenceinterval;ES,effectsize;—

,modelsthat

didnotrunbecauseof

limitedvariation.

aModelsareindicativeonlygiventhestatistical

estim

ationprocedures

used.

8 SKEEN et al by guest on December 21, 2020www.aappublications.org/newsDownloaded from

TABLE5DigitalandCombinedProgram

Component

Effect

SizesperOutcom

eArea

Program

Components

Prom

otionof

PositiveMentalHealth

Preventionof

AnxiousandDepressive

Symptom

ology

Preventionof

Violence,Aggression,and

Bullying

Preventionof

SubstanceUse

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

Activity

monitoring

and

scheduling

——

——

——

——

Alcoholand/ordrug

education

20.119(2

0.512to

0.275)

20.042(2

0.385to

0.301)

—0.081(2

1.190to

1.352)

20.402(20.543to

20.261)

20.401(0.543

to20.254)

——

Angermanagem

ent

——

——

——

——

Assertiveness

0.019(2

0.430to

0.468)

0.108(2

0.278to

0.493)

20.112(2

0.375to

0.151)

0.012(2

0.497to

0.520)

——

20.055(2

0.482to

0.371)

20.151(2

0.303to

0.001)

Behavioral

activation

——

——

——

——

Civicresponsibility

—0.095(2

0.112to

0.301)

—0.348(0.246

to0.451)

—0.104(2

0.153to

0.362)

——

Cognitive

restructuring

20.028(2

0.637to

0.582)

20.023(2

0.656to

0.610)

20.018(2

0.229to

0.193)

20.095(2

0.346to

0.155)

——

——

Communicationskills

0.080(2

0.492to

0.652)

0.118(2

0.257to

0.494)

—0.081(2

1.19

to1.352)

20.106(2

0.987to

0.775)

20.105(2

0.992to

0.781)

20.088(2

0.334to

0.158)

20.095(2

0.258to

0.068

Conflictresolution

20.192(2

0.427to

0.652)

20.012(2

0.749to

0.724)

—0.081(2

1.19

to1.352)

20.106(2

0.987to

0.775)

20.105(2

0.992to

0.781)

20.136(2

0.425to

0.152)

20.063(2

0.218to

0.093)

Coping

skills

20.301(2

0.651to

0.043)

20.181(0.555

to0.193)

20.101(2

0.291to

0.090)

20.038(2

0.264to

0.187)

——

20.153(2

0.460to

0.154)

20.194(2

0.340to

0.049)

Decision-making

0.241(2

1.156to

1.637)

0.208(2

1.257to

1.673)

——

20.106(2

0.987to

0.775)

20.105(2

0.992to

0.781)

20.056(2

0.285to

0.173)

20.110(2

0.272to

0.052)

Emotionalregulation

0.114(2

1.515to

1.742)

0.150(2

0.319to

0.619)

20.121(2

0.192to

20.049)

20.022(2

0.319to

0.275)

——

—20.062(2

0.373to

0.25)

Goal

setting

0.080(2

0.492to

0.652)

0.118(2

0.257to

0.494)

—0.081(2

1.190to

1.352)

——

—20.125(2

0.274to

0.024)

Insightbuilding

20.192(2

0.427to

0.042)

20.012(2

0.749to

0.724)

—0.081( 2

1.130to

1.352)

——

—20.062(2

0.373to

0.250)

Interpersonalrelationship

and/or

skills

0.220(2

0.171to

0.61)

0.300(2

0.004to

0.636)

20.096(2

0.224to

0.032)

20.033(2

0.290to

0.224)

20.100(2

0.445to

0.245)

20.098(0.467

to0.272)

20.316(2

0.425to

0.152)

20.127(2

0.289to

0.034)

Mentalhealth

literacy

20.259(2

0.627to

0.109)

20.175(2

0.530to

0.181)

0.018(2

0.300to

0.335)

0.105(2

0.278to

0.488)

——

20.055(2

0.482to

0.371)

20.042(2

0.219to

0.135)

Mindfulness

0.273(2

1.301to

1.848)

0.220(2

1.495to

1.936)

0.127(2

0.323to

0.577)

0.074(2

0.423to

0.571)

——

——

Problem

solving

0.019(2

0.430to

0.468)

0.108(2

0.278to

0.493)

20.128(2

0.191to

0.064)

20.095(2

0.317to

0.127)

20.037(2

0.232to

0.158)

20.135(2

0.331to

0.061)

—20.134(2

0.351to

0.083)

Relaxation

20.301(2

0.651to

0.048)

20.181(2

0.555to

0.193)

20.101(2

0.291to

0.09)

20.038(2

0.264to

0.187)

——

20.233(2

1.159to

0.693)

20.185(2

0.382to

0.011)

Resistingpeer

pressure

20.132(2

0.34

to0.577)

20.027(2

0.394to

0.339)

—0.081(2

1.190to

1.352)

20.402(2

0.543to

0.261)

20.401(2

0.548to

20.254)

20.099(2

0.406to

0.209)

20.142(2

0.552to

0.269)

Self-efficacy

20.132( 2

0.840to

0.577)

20.027(2

0.394to

0.339)

20.113(2

0.229to

0.003)

0.002(2

0.42

to0.423)

20.035(2

0.672to

0.602)

20.030(1.083

to1.023)

0.038(2

0.289to

0.365)

20.034(2

0.313to

0.245)

Self-monitoring

0.128(2

0.248to

0.503)

0.132(2

0.233to

0.498)

0.083(2

0.061to

0.227)

0.147(2

0.073to

0.366)

—0.104(2

0.153to

0.362)

20.019(2

0.268to

0.231

0.013(2

0.153to

0.179)

PEDIATRICS Volume 144, number 2, August 2019 9 by guest on December 21, 2020www.aappublications.org/newsDownloaded from

reduce depression and promotepositive mental health, as well asthose that were aimed to reduceaggression. Intervention programsthat included emotional regulationencompassed whole-classinterventions, cognitive behavioralinterventions,35 antibullyinginterventions,36 and guidedexpressive writing interventions,37 aswell as more broadly focused,integrated interventions.38 Many yogaand mindfulness-based interventionsalso employed an emotionalregulation component, aspractitioners guided adolescentsthrough meditative sessions in whichobserving as well as engaging withemotions was encouraged.23,39

Alcohol and drug education predictedlarger effect sizes for mental healthpromotion and interventionsaddressing violence. This termcovered a broad range of topics,including facts about alcohol,cannabis, and other illicit drugs,discussion about the risks of usingillegal substances, social influencesassociated with alcohol use,32,40–42

media influences and pressures touse substances,43–45 and parenteducation about engaging theirchildren in conversations aboutalcohol.24,46,47 Certain interventionsalso took a harm minimizationapproach, teaching adolescents aboutless harmful ways to use alcohol orways to reduce risk for themselves orothers.48–50 Delivery methods alsodiffered. For example, in 1 digitalintervention, participants are walkedthrough the consequences of a virtualnight of binge drinking.51 However,the reasons for the effect of alcoholand drug use on outcomes beyondsubstance use are unknown. It maybe because of shared risk andprotective factors between theseoutcomes and shared pathways toeffective prevention betweendifferent types of outcomes that havebeen “triggered” by teachingadolescents drug use preventioncontent.

For “Helping Adolescents Thrive,” it isevident that intervention content thatis strongly centered on interpersonaland emotional skills is most likely tobe effective across multiple outcomedomains. It is also possible that theactive components identified in thisreview, particularly interpersonalskills and emotional regulation, mayhave effects that extend beyond ourdefined scope of mental healthoutcomes to broader mental healthdomains. For example, in otherresearch, improvements in emotionalregulation have been shown toreduce risky sexual behavior duringadolescence52–54 because these skillsmay help adolescents developstronger and more equitablerelationships.52

Given that the evidence base is almostentirely from high-income countries(HICs), it will be essential to trackimplementation efforts if and whenthese interventions are adapted foruse in LMICs to ensure that they areimplemented in a culturally andcontextually valid and appropriatemanner.7 Specifically, developing anintervention package on the basis ofthese findings will require activeengagement with adolescents,particularly in low-resource settings,to translate relevant evidence-basedprinciples into feasible andacceptable intervention programsthat appeal to and effectively engageadolescents. Pursuing a user-centereddesign approach by employingmultiple stages of engagement andprototyping with adolescents, theirparents, their teachers, and othercommunity stakeholders tocoproduce the intervention package55

will significantly strengthen thedevelopment of the program and itsadaptability to different settings.

Again, although this was a globalreview, the publications eligible forinclusion were overwhelmingly basedin HICs. In studies from LMICs,adapted versions of evidence-basedinterventions from HICs are oftenused, which may affect the validityTA

BLE5

Continued

Program

Components

Prom

otionof

PositiveMentalHealth

Preventionof

AnxiousandDepressive

Symptom

ology

Preventionof

Violence,Aggression,and

Bullying

Preventionof

SubstanceUse

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

,2mo,ES

(95%

CI)

AllTimePoints,ES

(95%

CI)

Social

skills

20.132(2

0.840to

0.577)

20.027(2

0.394to

0.339)

—0.081(2

1.19

to1.352)

0.177(2

0.326to0.681)

0.182(2

0.361to

0.725)

—20.097(2

0.294to

0.101)

Stress

managem

ent

20.265(2

0.628to

0.098)

20.250(2

0.608to

0.108)

20.038(2

0.206to

0.13)

20.126(2

0.407to

0.155)

——

20.233(1.159

to0.693)

20.248(2

0.446to

0.049)

Supportnetworking

0.114(2

1.515to

1.742)

0.150(2

0.319to

0.619)

—0.081(2

1.19

to1.352)

0.177(2

0.326to0.681)

0.182(2

0.361to

0.725)

20.056(0.482

to0.371)

20.103(2

0.273to

0.068)

Forpositivementalh

ealth,a

positiveeffectsize

denotesabeneficialeffect.For

allother

outcom

es,a

negativeeffectsize

denotesabeneficialeffect.CI,confidenceinterval;ES,effectsize;—

,modelsthat

didnotrunbecauseof

limitedvariation.

10 SKEEN et al by guest on December 21, 2020www.aappublications.org/newsDownloaded from

and reliability of their results. Inaddition, studies with randomizeddesigns are more likely to be used toevaluate research programinterventions, whereas quasi-experimental and other designs areoften used for real-life interventions,meaning that restricting ourscreening to RCTs only may havelimited the applicability of thesefindings to nonresearch settings.56

The program components approachdepends on the quality of reporting inpublications. Brown et al19 note thatessential details required tounderstand content andimplementation are often missingfrom these publications. In the reviewby Singla et al,25 the authors furthernoted the lack of reporting aboutdosage for each component present.It was not always possible todetermine program fidelity or mean

dosage across participants, limitingthe strength of their analyses.57 Inthis review, few study authorsreported intervention components inenough detail to allow for replication;even fewer provided any form ofguidance as to how interventionscould be scaled up. Finally, a furtherlimitation to be considered is the riskof bias in the included studies.Although considered to be low acrossmost categories, allocationconcealment and random sequencegeneration were high or unclear forthe majority of studies, whereas insome cases, the nature of feasiblestudy designs for universallydelivered interventions (such as inschools) precluded blinding ofparticipants and outcomeassessment. Furthermore, the qualityof the body of evidence was notassessed by using the Grading of

Recommendations, Assessment,Development and Evaluation tool.

CONCLUSIONS

These are novel results that will beused to design a universallydelivered intervention as a part ofthe “Helping Adolescents Thrive”initiative. Further work should beundertaken to develop and testinterventions that use these corecomponents, especially inunderresourced settings in whichmultiple risk factors for pooradolescent health are present.

ABBREVIATIONS

HIC: high-income countryLMIC: low- and middle-income

countryRCT: randomized controlled trial

Dr Skeen designed the research plan, oversaw the full review process, and wrote the final study report; Drs Ross, Servili, Dua, and Tomlinson designed the research

plan; Ms Laurenzi, Ms Gordon, and Ms du Toit completed all qualitative and quantitative data extraction and contributed toward drafting, reviewing, and revising the

report; Ms Carvajal-Aguirre and Drs Eriksson de Carvalho, van der Westhuizen, Fleischmann, Kohl and Lund provided thorough input and feedback on the report at

various stages, as well as reviewed the manuscript; Dr Brand conducted all risk-of-bias assessments on the included studies, generated the related figure, and

reviewed the manuscript; Mr Dowdall contributed to the search strategy design and reviewed the manuscript; Dr Melendez-Torres conducted the meta-regression

analyses and contributed toward designing, drafting, reviewing, and revising the manuscript; and all authors approved the final manuscript as submitted and

agree to be accountable for all aspects of the work.

DOI: https://doi.org/10.1542/peds.2018-3488

Accepted for publication Apr 30, 2019

Address correspondence to Sarah Skeen, PhD, Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences,

Stellenbosch University, Education Building, Francie van Zijl Dr, Cape Town 7505, South Africa. E-mail: skeen@sun.ac.za

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Funded by the World Health Organization.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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