CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10–19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5–10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5–14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5–14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

The Sustainable Development Goals have brought attention to early childhood development and the intergenerational benefits of investing in early life.1  Since early childhood development underpins several of the Sustainable Development Goals, increased focus on this area is imperative to reach these global goals by 2030.1  It is estimated that 10% to 20% of children and adolescents worldwide experience mental health disorders, of which ∼50% manifest before age 14.1  In Europe and the Americas, mental health disorders are among the leading causes of disability-adjusted life-years among children aged 5 to 14 years.2  The burden of poor mental health and development prevents children from achieving their full potential, and has downstream impacts on the human capital of entire countries.

Most mental health conditions are underdiagnosed and undertreated, and children and adolescents face barriers to recovery, including stigma, shame, and inaccessibility of interventions.3  Intervening at an early age is critical because the consequences of mental illness extend into adulthood, leading to mental and physical harm across the life course.3  Additionally, multidirectional linkages exist between mental health conditions and other developmental concerns, such as risk-taking behaviors, poor education, and additional health problems.4  For example, depression and anxiety are leading causes of illness and disability among adolescents worldwide, with the potential to lead to self-harm, substance abuse, and risk-taking behaviors.3,5  Among adolescents aged 15 to 19, about 6% of all deaths are attributed to suicide and self-harm.5  Inadequate mental health support within schools and families highlights the need for more preventive and promotive efforts that are delivered earlier in life, and which improve children’s resilience, emotional regulation, and ability to avoid risky behaviors. More than ever before, the dramatic rise in mental health issues among school-aged children and adolescents (SACA) in the wake of the global coronavirus disease 2019 pandemic has increased awareness of this issue as it manifolds, with interest in mitigation strategies.6 

Previous reviews of mental health interventions in childhood have been focused on adolescents (10–19 years),7,8  and there is a dearth of comprehensive evidence syntheses specifically focused on school-aged children aged 5 to 10 years, and on preventive and promotive interventions that start in childhood and continue into adolescence. It is important to consider the needs of the school-age children age group in intervention efforts for several reasons. It is recognized that preventive interventions are more effective when implemented before the age of disease onset.9  Because of the early age of onset for many mental health conditions, these preventive interventions could be more effective at preventing mental health conditions in adolescents and young adults if they were implemented during the school-aged years.3  Despite this, programs designed, for example, to prevent substance use initiation are often delivered to children who are aged >12 years.10  Younger children, particularly those aged <8 years, may be better suited to receive nonsmoking messages because their perception of smoking is still largely negative.10  Likewise, primary school children (grades 1–5) may be better suited to receive antibullying interventions because the incidence of perpetration and victimization is highest in these children.11  Additionally, it is important to consider a life course perspective when designing mental health and positive development interventions because those implemented before adolescence can impact both adolescence and adulthood.7  Furthermore, in the current landscape of school closures and lockdowns, evidence continues to build on the impact of coronavirus disease 2019 on mental health in young children.1214  For example, early evidence from China illustrates a prevalence of anxiety and depressive symptoms of 19% and 23%, respectively, in primary school children after home confinement.15  For these reasons, this review will focus on interventions delivered to children aged <10 years, with the recognition that their delivery may often extend into early adolescence (10–14.9 years).

This review aims to summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5 to 14.9 in both high-income countries (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

We considered systematic reviews published until December 2020 that synthesized empirical studies using either experimental or quasi-experimental designs to evaluate the effectiveness of interventions.

For this overview, we primarily focused on those reviews that covered ages 5 to 14.9 years, which encompasses the period of “school-age” and includes late childhood and early adolescence. Although the primary focus is on ages 5 to 14.9 years, we still included reviews in which most of the sample’s target age range falls within our selected age limit. For example, we included reviews where the target age range of the intervention was 5 to 19 years or where the stated average age of participants fell between 5 and 14.9 years. In reviews that reported large age ranges (eg, 5–19 years), we were unable to parse out effects of younger age groups unless the data were disaggregated by age bands. In reviews that reported disaggregated data by age, we have prioritized children aged 5 to 9 years. We chose to include both HIC and LMIC because we did not expect to find evidence for all interventions in the LMIC context alone. However, when possible, we highlight LMIC evidence in this article where it existed. The reviews that focused on interventions delivered to special populations of children that were amenable to prevention (eg, those with chronic illness such as epilepsy) or nongeneralizable contexts (eg, conflict and humanitarian settings) were considered separately and are listed in Supplemental Information. This narrowing of scope was performed to allow for generalizability of effective interventions to the greatest number of children possible.

We focused on universal, generalizable, preventive interventions that aim to promote positive development, prevent mental disorders, improve mental health and well-being, or modify its determinants. We focused exclusively on preventive interventions because intervening before the onset of mental health problems is particularly beneficial in the context of young children who could potentially be spared of psychological distress later in adolescence or adulthood.

Several delivery strategies were considered, including school-based, community-based, digital, and mixed settings. An expanded listing of intervention types and associated delivery strategies can be found in Supplemental Information. Interventions that can be categorized into 1 or more of the following domains described below are the focus of this article. The domains were selected through expert discussion, the scope of previous overviews, and with focus on the greatest disease burden. Although some reviews could be categorized into multiple domains, we took a pragmatic approach to organizing them in the different sections of the narrative synthesis to ensure reviews of similar intervention types were considered together. Universal prevention interventions were placed in this category if the authors described the intervention as universal or covered a broad range of outcomes. The remaining interventions were categorized into each domain if either the intervention or outcome was specific to that domain. See Fig 1 for a general overview of the interventions, delivery strategies, and outcomes assessed.

  • Which universal prevention interventions are effective in improving multiple domains of SACA mental health status, development, and well-being?

  • Which interventions are effective in targeting the following key issues in SACA:

    • o bullying prevention interventions;

    • o substance use prevention interventions; and

    • o self-harm prevention interventions?

  • Which interventions are effective in supporting the following aspects of nurturing care in SACA:

    • o supporting safety and security, and preventing abuse and maltreatment;

    • o promoting responsive caregiving and parenting practices; and

    • o providing learning opportunities and promoting positive child development?

  • Which targeted interventions are effective for special populations of SACA that are amenable to prevention or nongeneralizable contexts?

Keyword searches were conducted in the following electronic databases: OVID Medline, The Cochrane Library, and Campbell Systematic Reviews. Each domain of interest described above used its own search strategy to identify relevant systematic reviews of interventions (see Supplemental Information). We also hand-searched the reference lists of key overviews to identify additional relevant systematic reviews. Although initial searches were conducted in 2019, an updated search was conducted until December 2020 to identify newer reviews.

At both title/abstract and full-text screening stages, a team of reviewers independently screened all records retrieved by the searches for relevance based on predefined eligibility criteria (see Supplemental Information). Any disagreements were resolved through discussion or by a third reviewer when necessary.

A standardized data extraction form was used to extract data from included reviews. The extraction form (see Supplemental Information) included general review characteristics, description of the target population, intervention types, delivery strategies, and data on outcomes and intervention effectiveness. The AMSTAR2 tool was used to assess the methodological quality of the included systematic reviews.16  Full-text data extraction and quality assessment for all included reviews was conducted independently by 2 reviewers. Pooled estimates (eg, risk ratios, odds ratios, and mean differences) from meta-analyses were extracted for a variety of mental health and positive development outcomes.

After removal of duplicates, 1926 reviews were title/abstract-screened for inclusion on the basis of the eligibility criteria previously described. Two-hundred twenty-nine citations were screened at full text and 162 studies were ultimately included (Fig 2). Sixty-seven studies did not meet our inclusion criteria and are presented in the Table of Excluded Studies (see Supplemental Information). The 162 reviews selected for final analysis were composed of 5 domains: nurturing care (n = 45),1762  self-harm (n = 3),6365  bullying (n = 18),11,6682  substance use (n = 22),83104  and universal prevention interventions (n = 74).105176 

Study Characteristics of Included Reviews

Twenty-nine reviews covered targeted interventions and were synthesized separately in Supplemental Information H. Four reviews included both universal and targeted populations.63,93,107,108  Study characteristics for the 137 included reviews are summarized in Table 1 and additional detail is provided in Supplemental Information.

Methodological Quality (AMSTAR2) of Included Reviews

AMSTAR2 assessments were performed for 78 reviews that reported meta-analyses.17,2131, 3335,37,39,40,45,46,48,50,51,56,58,59,61,63,64, 6769,76,81,84,85,8890,94,95,97,98, 100102,110,112,114,118120,123,125,129,138, 141,143,145,148150,154,155,157160,162, 165167,169,172175,177  Thirty-one studies (39.7%) were graded as “critically low,” 21 studies (26.9%) were graded as “low,” 6 studies (7.8%) were graded as “moderate,” and 20 studies (25.6%) were graded as “high” quality. Additional detail of assessments can be found in Supplemental Information.

Summary of the Effects of Interventions

Effects of interventions with quality ratings from all included reviews that were able to meta-analyze data on any mental health and/or positive development outcome have been summarized in Tables 26, by domain and delivery strategy.

The key effects of interventions on depression, anxiety, and externalizing symptoms/behavior have been summarized in Table 7, by delivery strategy.

Sixty-one reviews synthesized data or narratively reported on universal prevention interventions. Overall, we found evidence to support the effectiveness of psychosocial and exercise interventions to prevent negative mental health outcomes118,120,125,129,150,154, 155,159  and multicomponent positive psychology (PP), social–emotional learning (SEL), mindfulness, and mentoring-based interventions to promote well-being119,145,157,158  in school-aged children.

School-Based Interventions

Thirty reviews synthesized data on a range of school-based interventions. The greatest effects on mental health were found for psychosocial, internal resilience, SEL, and multicomponent, PP-based interventions. For example, resilience-focused interventions for children aged 5 to 18 years were effective relative to control for reducing depressive symptoms (standardized mean difference [SMD] = −0.08, 95% confidence interval [CI]: −0.14 to −0.01), internalizing (SMD = −0.21, 95% CI: −0.36 to −0.06) and externalizing problems (SMD = −0.18, 95% CI: −0.34 to −0.01), and general psychological distress (SMD = −0.11, 95% CI: −0.21 to −0.01).118  Similarly, psychosocial interventions that were delivered by teachers to school-aged children were effective in reducing internalizing outcomes (d = 0.133, 95% CI: 0.002 to 0.263).125 

Community-Based Interventions

Six reviews synthesized data on community-based interventions; however, the diversity of intervention components and outcomes assessed prevented the ability to synthesize results and make any definitive statements about effectiveness. In all cases, the findings were encouraging but required more research to make firm conclusions.118,131,137,140,145,147  Of note, cognitive behavioral therapy (CBT) was found to be an encouraging intervention at the parental/family context to prevent adolescent depression.118  Childhood pet ownership had a wide range of emotional health benefits, in particular for self-esteem and loneliness.144 

Mixed-Setting Interventions

Twenty reviews synthesized data on a broad range of interventions delivered in mixed settings. The greatest effects on mental health were found for exercise, CBT, mentoring, single-session therapy, and mindfulness-based interventions. For example, exercise-based interventions for school-aged children were effective in improving self-esteem (SMD = 0.51, 95% CI: 0.15 to 0.88),121  reducing externalizing problems (d = 0.320, 95% CI: 0.023 to 0.616), internalizing problems (d = 0.316, 95% CI: 0.073 to 0.558), improving self-concept (d = 0.297, 95% CI: 0.127 to 0.468), and academic achievement (d = 0.367, 95% CI: 0.038 to 0.697).156  CBT interventions reduced anxiety for children aged 3 to 8 years (SMD = −1.34, 95% CI: −1.59 to −1.09)160  and self-rated depression in children aged 8 to 24 years (SMD −0.11, 95% CI: −0.17 to −0.05).130 

Digital-Based Interventions

Five studies synthesized data on digital-based interventions, and all found encouraging results for the effectiveness of these interventions to achieve positive mental health outcomes. For example, results from online prevention interventions indicated a significant positive effect of computerized CBT on adolescents’ anxiety and depressive symptoms.115  Furthermore, universal psychosocial interventions delivered digitally were effective in improving mental health, in particular, interpersonal skills, emotional regulation, and alcohol and drug education, for children aged 10 to 19 years (effect size [ES] = 0.197, 95% CI: 0.016 to 0.379).154 

Fourteen reviews synthesized data or narratively reported on bullying prevention interventions. Overall, evidence supports school-based interventions and whole-school approaches.11,6770, 73,7678 

School-Based Interventions

Fourteen reviews examined school-based interventions. Evidence suggests that antibullying interventions are effective for a range of bullying-related outcomes. For example, interventions significantly reduced bullying (ES = −0.150; 95% CI: −0.191 to −0.109) and improved mental health (ES = −0.205; 95% CI: −0.277 to −0.133) at study endpoint.67  However, more research is needed to determine whether anti-cyberbullying interventions delivered in schools reduce cyberbullying behaviors.68,71,73  Reviews disagreed on which age group benefited most. Several reviews reported that bullying and victimization steadily increase with age, suggesting that intervening in elementary schools through preventive interventions may significantly reduce bullying-related outcomes.11,78 

Digital Interventions

One review also examined information and communication technology-mediated interventions delivered in schools, finding that more research is required.74 

Twenty-two reviews synthesized data or narratively reported on substance use prevention interventions. Most evidence supported the use of family- and school-based interventions to prevent substance use initiation in school-aged children.

Community-Based Interventions

Eight reviews examined community-based interventions and concluded that more research is needed. However, promising evidence was found for Youth Participatory Action Research to increase community awareness and multicomponent interventions to prevent smoking.85,104  Four reviews found that family-based interventions were effective for preventing substance abuse initiation.83,91,93,102  For example, interventions prevented smoking initiation (relative risk [RR] = 0.76; 95% CI: 0.68 to 0.84).102  One review concluded that family-based interventions were more effective when delivered in early adolescence.93 

School-Based Interventions

Five reviews examined school-based interventions. Combining social competence and influence components had small but consistent positive effects on drug use prevention (odds ratio [OR] = 0.50; 95% CI: 0.28 to 0.87).90,101  Health education and social learning components in combination with oral, written, and audiovisual support material improved attitudes toward drugs (d = 0.44; 95% CI: 0.33 to 0.54).88  Skills-based components improved self-efficacy compared with affective components, but had the same effect as knowledge-based components on drug knowledge. Affective components improved decision-making and drug knowledge compared with knowledge-based components.89 

Digital-Based Interventions

Three reviews found little, though promising, evidence to support digital-based interventions. One review reported reduced cannabis use (OR = 0.33; 95% CI: 0.13 to 0.54) persisting to 12 months.84 

Mixed-Setting Interventions

Three reviews examined mixed settings. Community- and school-based mentoring prevented substance use.100  Compared with other delivery strategies; universal school-based interventions that targeted multiple risk behaviors prevented substance use.97 

Other Interventions

Three reviews included interventions without reference to a specific delivery strategy. Taxation, public consumption bans, advertising restrictions, and minimum legal age reduce alcohol and tobacco use.99  Universal multicomponent interventions reduce alcohol use.92 

Two reviews synthesized data or narratively reported on self-harm prevention interventions. Self-harm is more common in adolescents (12–18 years) than children.63  However, interventions targeted at school-aged children may help to prevent adolescent self-harm.

Mixed-Setting Interventions

One review examined interventions that were designed to improve the ability of gatekeepers to prevent suicide-related crises in young people by recognizing risks and responding appropriately.65  Gatekeeper training is associated with significant moderate-to-large improvements in suicide literacy outcomes (eg, knowledge of suicide, confidence to intervene, and attitudes toward suicide).65  The second review examined primary prevention interventions, such as knowledge promotion, reducing access to means, local media reporting, local suicide plans, and screening for suicide risk.63  The review assessed multiple settings and found that school-based interventions prevent suicidal ideation and attempts short term, and possibly suicide attempts long term.63 

Thirty-eight reviews synthesized data or narratively reported on nurturing care interventions. Twenty-nine studies were identified which reported mixed effects of interventions on children's social, emotional, and behavioral outcomes in a wide range of delivery strategies. Nine out of 29 studies reported safety and security interventions, which focused on prevention of child and adolescent maltreatment, and promotion of mental and physical well-being in abused or neglected children. Early learning and positive development interventions were reported in 16 reviews, which focused on academics, positive development, and positive connections to improve developmental outcomes and a positive transition into adulthood. School- and community-based interventions had positive effects on school-aged children’s mental health and developmental outcomes.

Community-Based Interventions

Eighteen reviews reported family-based interventions. Improved parenting responsiveness resulted in better health and development in younger children, especially in poor settings.41  The Multilevel Triple P-Positive Parenting Program system showed improvements in children's social, emotional, and behavioral outcomes (SMD = 0.525; 95% CI: 0.358 to 0.692); parenting practices (SMD = 0.498; 95% CI: 0.362 to 0.634); parenting satisfaction and efficacy (SMD = 0.551; 95% CI: 0.372 to 0.730); parental adjustment (SMD = 0.481; 95% CI: 0.321 to 0.641); and parental relationship (SMD = 0.230; 95% CI: 0.136 to 0.325).48  Physical activity interventions showed improvements in motor skills and cognitive development in children aged <6 years.36  After-school programs promoted positive behaviors, including self-care (SMD = 0.503; 95% CI: 0.097 to 0.910) and reduced negative behaviors.37  Physical activity interventions improved self-concept (hedges g = 0.49; 95% CI: 0.10 to 0.88), self-worth (g = 0.31; 95% CI: 0.13 to 0.49), and inhibitory control (d = 0.2; 95% CI: 0.03 to 0.37) in children aged 0 to 19 years.26,28 

School-Based Interventions

School-based programs for sexual abuse prevention improved protective behaviors (OR = 5.71; 95% CI: 1.98 to 16.51) and knowledge (SMD = 0.61; 95% CI: 0.45 to 0.78).56  School-based universal SEL interventions significantly improved social and emotional distress (mean effect [ME] = 0.24; 95% CI: 0.14 to 0.35); attitudes (ME = 0.23; 95% CI: 0.16 to 0.30); positive behavior (ME = 0.24; 95% CI: 0.16 to 0.32); conduct problems (ME = 0.22; 95% CI: 0.16 to 0.29); and academic performance (ME = 0.27; 95% CI: 0.15 to 0.39) in children aged 5 to 18 years.24  After-school programs demonstrated a significant increase in overall effect (SMD = 0.22; 95% CI: 0.16 to 0.29); self-perceptions (SMD = 0.34; 95% CI: 0.23 to 0.46); positive behaviors (SMD = 0.19; 95% CI: 0.10 to 0.29); levels of academic achievement (SMD = 0.17; 95% CI:0.06 to 0.29); and reductions in problem behaviors (SMD = 0.19 95% CI: 0.10 to 0.27).23  School‐based universal programs34  and pull-out programs35  targeting aggressive behavior in children and adolescents reported positive effects with short, intensive interventions compared with extended yearlong programs. Universal school-based resilience interventions25  and health education curriculums30  showed reduction in illicit substance use.

Mixed-Setting Interventions

Fifteen reviews reported on mixed settings including schools, day care, communities, and households. Community-based parenting interventions showed positive effects on measures of good parenting, with positive flow-on effects to some aspects of challenging adolescent behaviors including parent–child communication, smoking reduction, and parental reactions.43,47,49  Individual and group-based, child-focused, and behavioral parenting interventions showed reduction in disruptive behavior problems (SMD = −0.38; 95% CI: −0.51 to −0.24) among school-aged children in LMIC.40  Use of activity- and occupation-based interventions, including video game interventions, showed positive effects on mental, behavioral, and physical health in children and youth.19,32  Positive youth development (PYD) programs showed positive effects on behaviors, including substance use and risky sexual activity, and/or more distal developmental outcomes.20,22 

Evidence from LMIC

Forty-nine reviews covered populations in both HIC and LMIC; however, most studies captured by these reviews were in HIC and, thus, makes generalizability of findings to LMIC difficult. We found 8 reviews which encompassed LMIC studies only. Interventions considered were PYD programs, school tobacco policies, school-based antibullying or mental health promotion interventions, and peer-facilitated, community-based interventions for mental health disorders and substance use. There was promising evidence for PYD programs, and findings from multiple reviews suggest that interventions that promote mental health in young people can be implemented effectively in LMIC school and community settings. However, overwhelmingly, all reviews point to the dearth of evidence that exists for interventions in the LMIC context, where some reviews only captured 1 study for inclusion.

We summarize findings from 162 reviews, where 78 studies meta-analyzed data. Findings for targeted interventions (n = 29) have been summarized in Supplemental Information. Of the included studies, 39.7% had critically low-quality ratings, 26.9% were low, 25.6% were high, and 7.8% were moderate. Evidence from universal prevention interventions showed overall positive effects on youth development and prevention of poor mental health outcomes, where most interventions were school-based. Antibullying interventions reduced bullying and victimization where the majority were school-based, with limited evidence for digital interventions. Community- and school-based interventions were found to prevent substance abuse; however, the evidence for digital interventions was limited. Only 2 reviews examined interventions for the prevention of self-harm and found evidence for gatekeeper training and school-based interventions. School- and community-based interventions had positive effects on children and adolescents’ early learning and positive development. Lastly, there was mixed evidence overall for the effectiveness of home-based interventions to enhance responsive caregiving and child safety.

Evidence for key impacts on the greatest causes of mental illness burden in the school-age group suggest that school-based multicomponent PP158  and universal prevention interventions116,132  were effective in reducing depression and anxiety in predominantly HIC. Furthermore, universal, resilience-focused interventions118  were found to be effective in reducing depression and externalizing symptoms in HIC. School-based mental health promotion interventions108  and interventions describing modules of mental health126  were effective in reducing depression and anxiety in LMIC. Furthermore, peer outreach, counseling, and education interventions were effective in reducing depression in LMIC.147 

In community-based settings, evidence-based youth mental and behavioral health disorder prevention interventions146  were effective in reducing depression, and the FAST program50  was effective in reducing externalizing symptoms in HIC. Computerized CBT and digital health interventions were effective in reducing depression and anxiety115,131  in HIC. Mindfulness-based interventions119  delivered through mixed settings were effective in reducing depression and anxiety in LMIC and HIC.

When discussing evidence specifically from LMIC, school-based PYD programs provided the strongest evidence for positive development (eg, reduced risky sexual behavior, substance use, and interpersonal violence) and mental health outcomes (eg, increased emotional stability and self-esteem) in children; however, more research is urgently required to identify effective preventive interventions for children exposed to a range of adversities and types of mental disorders in the LMIC context.

Our overview of reviews was primarily limited by our inability to synthesize and interpret research findings from the included systematic reviews because of inadequate or varied reporting of pooled data from the primary studies.

Despite the breadth of reviews found, there remain several significant gaps in the literature. Firstly, there were a limited number of studies focused on low education, low-income, and conflict-struck settings. Some outcome measures (eg, child abuse and neglect) may be more prevalent and underreported in these contexts.178  Furthermore, there were a paucity of studies conducted across all delivery strategies. In particular, digital interventions were understudied compared with school-based interventions which were most often discussed across all domains. Given there are many school-aged children who never attend school, there is a need for interventions conducted outside of the school setting to improve coverage to all school-aged children. Only 2 studies were captured in the self-harm domain, highlighting the need for more research focused on self-harm prevention. Lastly, many of the included reviews captured children into adolescence (eg, from 0 to 18 years old). There is need for more research targeting younger children (<10 years) given that intervening at an early age is critical to prevent mental illness in adolescence and adulthood.

Given the identified gaps in the literature and methodological and clinical heterogeneity of included reviews, we are limited in our ability to make definitive statements about effectiveness of interventions, rendering policy interpretation and implementation challenging. However, there were some common recommendations that emerged from the literature. First, a common recommendation across several domains is to implement multicomponent and multilevel interventions.41,48,78,90,112,158  Several reviews suggest adding school-based components to comprehensive antibullying interventions78,90  and integrating home-level responsive parenting interventions into child survival programs.41,48  Furthermore, groups involved in intervention implementation, such as school health personnel, should be involved in intervention development and supported during implementation.78  Several reviews also recommend training these groups for effective intervention programming.41,65,78  Finally, given most universal prevention interventions were delivered in schools, there is evidence for the use of school-based universal prevention programs.

  • Positive youth development and after-school programs had encouraging effects on academic achievements and problematic behaviors, including substance use and risky sexual activity, and/or more distal developmental outcomes, such as employment and health indicators. Interventions targeting positive development showed improvements at different contextual levels including school, homes, and community settings.

  • School-based antibullying interventions reduced bullying perpetration and victimization outcomes.

  • Community- and school-based interventions prevented substance use initiation.

  • A limited number of reviews addressed self-harm prevention. Evidence suggests that gatekeeper training improves suicide literacy outcomes in gatekeepers, and school-based interventions prevent suicidal ideation and attempts in youth.

  • Responsive caregiving and parenting programs supported nurturing care through improvements in children's social, emotional, and behavioral outcomes.

  • The largest number of included studies had consistent findings that showed positive effects from universal prevention interventions on a large range of mental health outcomes.

  • Overall, more research is required in LMIC contexts that focuses on digital interventions, interventions provided outside of the school context, prevention of self-harm, and especially interventions targeting young children (aged <10 years).

High levels of statistical heterogeneity and diversity of study design, instruments, populations, interventions, and settings were common. This limited our ability to make comparisons and definitive statements about effectiveness of interventions, rendering policy interpretation and implementation challenging. Overall, this overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered. Furthermore, there is urgent need for more research specifically in the LMIC context to improve coverage and extend findings to all SACA.

We thank Nabeela Ilyas and Christine Leung for their contributions to this article.

Dr Bhutta conceptualized and designed the study; Mr Vaivada conceptualized and designed the study and drafted the initial manuscript; Ms Harrison, Dr Irfan, Ms Sharma, and Ms Zaman screened the search results, screened the retrieved papers against the inclusion criteria, appraised the quality of papers, extracted the data, completed data tabulation and synthesis, and drafted the initial manuscript; and all authors reviewed, revised, and approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

FUNDING: This work was supported by a grant from the International Development Research Centre (#109010-001). The funder did not participate in the work. Core funding support was also provided by the SickKids Centre for Global Child Health in Toronto.

CONFLICT OF INTEREST DISCLAIMER: The authors have no conflicts of interest relevant to this article to disclose.

CBT

cognitive behavioral therapy

CI

confidence interval

ES

effect size

HIC

high-income countries

LMIC

low- and middle-income countries

ME

mean effect

OR

odds ratio

PP

positive psychology

PYD

positive youth development

SACA

school-aged children and adolescents

SMD

standardized mean difference

SEL

social–emotional learning

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