Enhancing the Emotional and Social Skills of the Youth to Promote their Wellbeing and Positive Development: A Systematic Review of Universal School-based Randomized Controlled Trials



Federica Sancassiani1, *, Elisa Pintus 1, Arne Holte 2, Peter Paulus3, Maria Francesca Moro1, Giulia Cossu1, Matthias C Angermeyer1, Mauro Giovanni Carta 1, Jutta Lindert 4
1 Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy
2 Norwegian Institute of Public Health, Oslo, Norway
3 Institute of Psychologie & Center for Applied Sciences of Health, Leuphana University Lueneburg, Germany
4 University of Applied Sciences Emden, Emden, Germany; Brandeis University, Waltham, USA


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© Sancassiani et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Centro di Psichiatria di Consultazione e Psicosomatica, University Hospital, Cagliari, Italy; Tel: +39/070/6093495; E-mail: federicasancassiani@yahoo.it


Abstract

Background:

The acquisition of social and emotional skills is associated with positive youth development, character education, healthy lifestyle behaviours, reduction in depression and anxiety, conduct disorders, violence, bullying, conflict, and anger. School-based interventions aimed to enhance these skills go beyond a problem-focused approach to embrace a more positive view of health; they could also improve the youth’s wellbeing.

Aim:

To describe the main features and to establish the effectiveness of universal school-based RCTs for children and the youth, aimed to promote their psychosocial wellbeing, positive development, healthy lifestyle behaviours and/or academic performance by improving their emotional and social skills.

Methods:

Systematic review by searching for relevant papers in PubMed/Medline with the following key words: “mental health” OR “wellbeing” OR “health promotion” OR “emotional learning” OR “social learning” OR “emotional and social learning” OR “positive youth development” OR “life skills” OR “life skills training” AND “school”. Interval was set from January 2000 to April 2014.

Results:

1,984 papers were identified through the search. Out of them 22 RCTs were included. While most interventions were characterized by a whole-school approach and SAFE practices, few studies only used standardized measures to assess outcomes, or had collected follow-up data after ≥ 6 months. The results of all these trials were examined and discussed.

Conclusion:

Universal school-based RCTs to enhance emotional and social skills showed controversial findings, due to some methodological issues mainly. Nevertheless they show promising outcomes that are relatively far-reaching for children and youth wellbeing and therefore are important in the real world.

Keywords: Children wellbeing, emotional skills, health promotion, positive development, randomised controlled trials, school, social skills.



BACKGROUND

The WHO [1] defines mental health as “a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. Wellbeing itself is one of the aims of the WHO strategy “Health 2020”, which states that mental health promotion involves building peoples’ resilience against various stressors in their lives [1-6]. Resilience is defined as the universal capacity that allows a person, group or community to respond proactively to new situations and to prevent, minimize or overcome the damaging effects of adversities [1, 2, 7].

Research shows that mental health promotion is most effective when it takes place early in a persons’ life: therefore school is a favourable implementation setting for these programmes [1-4, 8-10]. The WHO [4] states that “there is ample evidence that school based programs in elementary,middle and high schools can positively influence mental health and reduce risk factors, emotional and behavioural problems through socio-emotional learning and ecological interventions”.

Furthermore, recent evidences about school-based interventions promoting mental health and wellbeing point out the need to go beyond a problem-focused approach and embrace a more positive view of mental health [9, 11-16]. This shift involves the acknowledgment that childrens’ and youths’ wellbeing and mental health are not only influenced by the absence of problems and risk-need concerns, but are also impacted by individual skills and by those positive factors in their social settings that contribute to positive growth and development [10, 12].

From this perspective, extensive research in school, community, and clinical settings has led several authors to offer recommendations for effective school-based interventions on emotional and social skills to promote positive youth development, mental health and wellbeing [9, 12, 17, 18]. These interventions include a whole school approach, in which multi-component interventions involve students, teachers, the school environment and the community by participatory ways whereby everyone, driven by common purposes, can give their own contribution from different points of view and roles, with continuous implementation for more than one year [18-20]. Furthermore, research shows four recommended practices – Sequenced, Active, Focused, Explicit - to implement good programs under the acronym SAFE [9]. The programs could be effective if they use a sequenced step-by-step training approach (Sequenced), active forms of learning (Active), devote sufficient time to skill development (Focused), and have explicit learning goals (Explicit) [21-24].

These complex features show that contemporary schools are expected to do more, but often with poorer resources than they used to have in the past [18]. A comprehensive mission for schools is not only to reach good academic achievements and knowledge, but also to promote personal and social responsibility, health, caring and citizenship and positive development for all students [18].

Positive youth development includes ecological, asset or strength-based approaches that promote healthy growth through supportive community environments and good relationships [25, 26]. The focus is on building relationships with caring adults that support engagement in challenging activities in which the youth are active participants, rather than solely the recipients of services or support [25-28].

Catalano et al. [12] identified a set of recognizable features of positive youth development programs, some school-based too, which seek to achieve one or more of the following objectives: promote bonding, social, emotional, cognitive, behavioral, and moral competence; foster resilience, self-determination, spirituality, self-efficacy, clear and positive identity, belief in the future, prosocial norms (healthy standards for behavior); provide recognition of positive behavior and opportunities for prosocial involvement.

Furthermore, the WHO [8] defines life skills as “abilities for adaptive and positive behavior, that enable individuals to deal effectively with the demand and challenges of every day life”. The nature and the definition of life skills are likely to differ across cultures and settings, but there is a core set of skills, as defined by the WHO [8]: decision making, problem solving, creative thinking, critical thinking, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions, and coping with stress.

Recent reviews have noted that certain psychosocial and developmental prevention programs such as the Life Skills Training (LST) [29-31] can be effective in preventing early-stage drug use (tobacco, alcohol, marijuana), alcohol misuse and risky sexual behaviours. LST is focused on teaching social resistance skills or a set of general life skills, either alone or in combination, and it can produce durable prevention effects [29, 32-34].

Furthermore in the 1990s’, the Fetzer Insitute first introduced the term Social and Emotional Learning (SEL) to identify those interventions that can integrate the promotion of personal skills to reduce risk factors and enhance protective factors for positive youth development [12, 18, 35-38]. SEL is the process of acquiring core competencies to recognize and manage emotions, set and achieve positive goals, appreciate the perspectives of others, establish and maintain positive relationships, make responsible decisions, and handle interpersonal situations constructively [35]. SEL programs are focused on the development of a whole set of cognitive, affective, and behavioural competencies: self-awareness, self-management, social awareness, relationship skills, and responsible decision making [39]. These skills mediate better academic performance, healthy behaviours, positive social behaviours, fewer conduct problems, less emotional distress, and citizenship [18, 40, 41].

AIM

This systematic review was carried out to describe the main features and to establish the effectiveness of universal school-based RCTs for children and the young aged 0-17 years old, aimed to promote their psychosocial wellbeing, positive development, healthy lifestyle behaviors and/or academic performance by improving their emotional and social skills.

METHOD

Identification of the Studies

The search of the significant articles was carried out in PubMed/Medline with the following key words: “mental health” OR “wellbeing” OR “health promotion” OR “emotional learning” OR “social learning” OR “emotional and social learning” OR “positive youth development” OR “life skills” OR “life skills training” AND “school”.

Inclusion Criteria

The studies included in this review were randomized controlled trials, in which universal school-based interventions on students’ emotional and social skills to promote their wellbeing were compared to similar interventions, interventions as usual or no intervention, with samples of students aged 0-17 years old.

Interval was set from January 2000 to April 2014.

Exclusion Criteria

Any study other than randomized controlled trials, and multiple publications on the same cohorts, studies with data analysis still pending, those conducted on indicated populations of students (i.e. at risk for some psychiatric disorder, or with low income, or belonging to ethnic minorities) and those not written in English were excluded.

The process of inclusion/exclusion of studies is summarized in Fig. (1) by Prisma Flow Diagram.

Fig. (1).

Prisma flow diagram about studies’ inclusion process.


Multiple Publications on the Same Cohorts

Multiple interventions from the same report were analyzed separately if the data related to distinct outcomes or contained separate cohorts. For multiple publications evaluating the same intervention but containing different outcome data at the post-hoc or follow-up analysis for the same cohort, only the data on the last published paper were reported with reference to the others (see Tables).

Studies Not Assessing Emotional or Social Skills as Mediators

The papers on the interventions focused on outcomes related to physical health or unhealthy behaviors only (i.e. substance abuse), without assessment of those psychological or social health variables considered as mediators by the authors, were included and summarised in dedicated tables.

Content and Thematic Analysis

Data were extracted from the included papers and organized in tables using four main criteria.

The first criterion was the kind of the implemented interventions (Life Skills Training; Life Skills Training programs focused on behavioural outcomes only; Miscellany of programs targeting psychological and social skills).

The second was the study content: Country of implementation, year of publication, students’ grade, controls, sample size, whole school approach level of the intervention, duration and assessment timeline.

The third was the results: outcomes and mediators considered by the authors, measures and tools used.

The last criterion regarded the quality features of the studies (using standardised outcome measures; including ≥6 months follow-up assessment after the conclusion of the intervention or waves of data across 2 academic years at least); effectiveness (p <0.05); fitting characteristics of SAFE practices (Sequenced; Active; Focused; Explicit); fitting levels of whole school approach (students; teachers; parents; school environment; community). These features were coded dichotomously (yes/no).

Outcomes

We considered the main and/or secondary outcomes, as well as the mediators, as declared by the authors.

RESULTS

Characteristics

The search included 22 RCTs involving 49,169 students aged 6-18 (5-12 school grades).

Out of these, 12 (54%) studies were conducted in USA [32, 42-44 (study 1 and 2), 45, 55-60], 3 (14%) in Europe [20, 46, 47] and 7 (32%) in other countries (Australia, Canada, Mexico, South Africa, Hong Kong, Taiwan, Thailand) [48-54].

Regarding the educational level of the students participating in the studies, 1 (4.5%) study involved 2nd grade students [47] 1 (4.5%) involved 3rd grade students [55], 2 (9%) involved 5th grade students [43, 46], 4 (18.2%) involved 6th grade students [42, 44 (study 1 and 2), 54], 4 (18.2%) involved 7th grade students [32, 48, 56, 57], 2 (9%) involved 8th grade students [49, 52]; 1 (4.5%) involved 9th grade students [58]; 1 (4.5%) study involved 5-8 grades students [53], 1 (4.5%) study involved 7-12 grades students [50], 1 (4.5%) study involved 9-11 grades students [59], 1 (4.5%) study involved 10-12 grades students [51], 2 (9%) studies involved 11-12 grades students [45, 60].

Table 1a.

”Life Skills Training“ (LST) programs measuring both emotional and social skills, and healthy behavior outcomes.


Study Country Interventions (Focus; Sample Size) Controls (Focus; Sample Size) Students’ Population Size Students’ Age/Grade at Baseline Duration and Assessment Timeline
Buhler et al., [46] Germany “General Life Competencies and Skills” - Life Skills Training (program to to promote life skills and prevent substances use; N= 256) Treatment as usual (Not defined; N=192) N=448 5 grade 1 academic year (pre-post)
Eisen et al., [42]
- see also: Eisen et al., [68]
USA Lions–Quest Skills for Adolescents (SFA) (life skills training’ program to promote life skills and prevent drug use; N=not reported) Standard care (Not defined; N=not reported) N= 7426 6 grade 1 academic year (40 key sessions) (baseline at the and of year 6 and post-treatment at the end of year 7) (pre-post).
Fitzpatrick et al., [20] Ireland Working Things Out - Social, Personal and Health Education Programme (SPHP) - Enhanced (EP) (life skills training’ program plus mental health promotion component to promote life skills, shool ethos and prevent emotional and behavioural difficulties; N= 527 Social, Personal and Health Education Programme (SPHP)Standard (SP) (life skills training’ program; N=545 N=1072 7-11 grades 8 months (pre-post + 6 months follow-up)
Huang et al., [48] Taiwan Life Skills Training (program based on Theaory of Planned Behavior (TPB) to promote life skills and prevent drugs use; N= 143) - Conventional (conventional didactic teaching about the harmful effects of using illicit drugs and drugs refusal skills for two 45-minutes sessions; N=142)
-No intervention (N=156)
N=441 7 grade 16 weeks + 8-10 weeks homeworks (pre-post)
Johnson et al., [43] USA Think Smart – Life Skills Training (program to promote life skills and prevent use of harmfull legal products (HLP); N= 630) No intervention (N= 586) N=1216 5 grade 12 weeks (core sessions) + 3 weeks after 2-3 months from core sessions (booster sessions) (wave 1 – baseline: prior to the start of core sessions; wave 2 – post-treatment: after the end of booster sessions; wave 3: 6 months follow-up)
Resnicow et al., [49] South Africa - Life Skills Training ( life skills training’ program to promote life skills and prevent drug use; N=1717)
- KEEP LEFT (Harm minimization program to prevent substance use; N=1978)
Usual tobacco and substance use education (N=1571) N = 5266 8 grade (baseline) 2 academic years (8 units for each of grade 8 and 9) (pre-1 post at the end of grade 8-1 post test al the end of grade 9)
Seal, [50] Thailand Life Skills Training (program to promote life skills and prevent tobacco and drug use; N=85) Treatment as usual (Tobacco and drug education curriculum normally provided; N=85) N=170 7-12 grades 10 class period (≈60 min each or 10 class hours of content) (pre-post after 6 months)
Walker et al., [51] Mexico - Life Skills Training (programe to promote life skills, condome use and HIV knowledge; N = not reported )
- Life Skills Training + module on emergency contraception (programe to promote life skills, condome use, HIV knowledge and emergency contraception; n = not reported)
Biology based sex education course (N = not reported) N= 10.954 10-12 grades 1 academic year (15 week, 30 hour course (16 weeks, 32 hours for the promotion with contraception
arm) (pre-post + 16 months follow-up)
Table 1c.

Different programs (than LST) on emotional and social skills, psychological wellbeing indicators, healthy behaviors, academic performance outcomes.


Study Country Interventions (Focus; Sample Size) Controls (Focus; Sample Size) Students’ Population Size Students’ Age/Grade at Baseline Duration and Assessment Timeline
Bond et al., [52] Australia Gatehouse Project (program on emotional wellbeing promotion to prevent substances use; baseline: N=1335) No intervention (N=1343) N= 2678 8 grade 3 academic years (4 waves of students: baseline at the beginning of year 8; other assessments: at the and of year 8, 9, 10 (pre-post)
He et al., [53] Canada Free Fruit and Vegetable Snacks (FFVS) plus Enhanced Nutrition Education (ENE) (program offering either one fruit or one vegetable serving three time per week plus “Paint Your Plate! Create a Master Piece: Vegetables and Fruit Action Guide for Schools”, a curriculum-based resources for teachers to enhance students’ awareness, knowledge, self-efficacy, preference, intention and willingness to increase fruit and vegetable consumption; N=3104) -Free Fruit and Vegetable Snacks (FFVS) (program offering either one fruit or one vegetable serving three time per week; N=1625)
-No intervention (N=1659)
N=6388 5-8 grades 21 weeks (pre-post)
Holen et al., [47] Norway Zippis’ Friends (program to strenght childrens’ coping skills; N=686) No intervention (N = 638) N = 1324 2 grade 24 weeks (pre-post)
Jones et al., [55] USA 4Rs Social-Emotional Learning Program (Reading, wRiting, Respect and Resolution) (program to prevent social-emotional, behavioral and academic problems; N=630) No intervention (N=554) N=1184 3 grade 2 academic years (wave 1 – baseline, fall third grade; wave 2 – spring third grade; wave 3 – fall fourth grade; wave 4 – spring fourth grade)
Khalsha et al., [57] USA Yoga Ed Program (program to increase psychosocial wellbeing and mental health; N= 74) Regular physical education (Not defined; N= 47) N=121 7 grade 11 weeks (pre-post)
Melnik et al., [59] USA COPE (Creating Oppurtunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) Program (cognitive-behavioral skills-building intervention with 20 minutes of physical activity integrated into a health course to promote healthy lifestyles behaviors, good MBI, good psychosocial outcomes, social skills, and academic performance; N=358) Attention program (Healthy Teen) (manualized attenction program focused on safety and common health topic/issue for teens. Control students received also a manual with homeworks and reviewed with their parents a newsletter sent to their homes; N=421) N=779 9-11 grades 15 weeks (pre-post + 6 months follow up)
Noogle et al., [60] USA Kripalu Yoga (program to increase psychosocial wellbeing and self-regulatory skills; N=36) Regular physical education (Not defined; N=15) N=51 11-12 grades 10 weeks (pre-post)
Shek et al. [54]
- see also:
Shek et al.,;
[71; 72;
73; 74;
75; 76]
Hong Kong PATHS (Positive Adolescent Training through Holistic Social Programmes ) (programme to promote positive development and reduce risks/problem behaviors; N=2662) No intervention (N=3272) N=5934 6 grade (baseline) 3 academic years (400 hours in each school year for each grade) (8 year waves: pre- 5 measures + 2 post interventions)
Werch et al., [45] USA 3 interventions based on Behavioral-Image Model (BIM) (brief interventions based on printed text and scripted messages which attpted to elicit an image of successful young adults and to show the benefits of being successful in terms of enhanced self-image):
-Plan for Success Goal clarification Survey (Goal Survey) (self administered instrument to identify behaviors that would improve their future chances of being successful, as well as those that would interfere, along with improvents in the way they would view the selves or others might see th resulting from becoming a more successful young adult; N = 113);
-Goal Survey plus a Path to Success Goal Plan (Contract)(The Contract was designed to assist participants in selecting self-concordant goals they felt lead to a more successful and happy life, which have been found to facilitate behavioral change; N = 113);
-Goal Survey plus a Career Consultation (Consult) (The Consult was designed to provide image-based feedback tailored to targeted personal development and health behaviors; N = 109)
N = 335 11-12 grades 1 acad ic year (max 20-minute s sessions during regular school hours; pre and 1 month post)

19 studies were published in 2006-2014 (86%) [20, 43, 44 (study 1 and 2), 45-51, 53-60;] 3 (14%) studies were published in 2000-2005 [32, 42, 52].

Kind of the Interventions Implemented

Life Skills Training (LST) was the kind of intervention tested in 13 (59%) trials [20, 32, 42-44, 46, 48-51, 56, 58]. Among them, 5 (38.5%) were conducted by testing effectiveness of LST on healthy behaviours without assessing social and psychological skills as secondary outcomes or mediators [32, 44 (study 1 and 2), 56, 58].

Regarding the studies measuring the efficacy of Life Skills Training (LST) on both social and emotional skills, and healthy behaviours, 6 (75%) of them took into account both kinds of outcomes [42, 43, 46, 49-51]; 2 (25%) trials considered social and emotional skills only [20, 48].

Finally, 9 (41%) trials had miscellanea of different programs on students’ wellbeing outcomes (emotional and social skills, healthy lifestyle behaviors, academic performance, psychological wellbeing) [45, 47, 52-55, 57, 59, 60].

Quality Features of the Studies

Regarding the use of standardized outcome measures, 10 (45%) trials were conducted with standardized tools [32, 42, 45, 47, 53, 54, 55, 57, 59, 60]. 3 (14%) studies used both standardized and not-standardized measures [20, 52, 58]. Finally, 9 (41%) studies were not conducted by standardized tools [43, 44 (study 1 and 2), 46, 48-51, 56].

Regarding the assessment timeline, 9 (41%) studies included a ≥ 6 month follow-up after the end of the intervention [20, 43, 44 (study 1 and 2), 50, 51, 54, 56, 59]. Among them, 4 (18% of 22) included also at least two academic years of repeated measures (data waves) [44 (study 1 and 2), 54, 56]. Only 2 (9%) studies reported at least two academic years of repeated measures (data waves) design without a ≥ 6 month follow-up after the end of the intervention [52, 55]. Finally, 11 (50%) studies reported neither a ≥ 6 month follow-up after the end of the intervention, nor a minimum of two academic years of repeated measures (data waves) [32, 42, 45-49, 53, 57, 58, 60].

Regarding SAFE (Sequenced, Active, Focused, Explicit) practices, in all of 22 (100%) trials at least three of these practices were used.

The whole school approach levels were the same in 12 (54.5%) studies, which means that the interventions involved students, their teachers and the school environment but not their parents and community [32, 42-44 (study 2), 46-49, 51, 52, 55, 56]. In 2 (9%) studies, interventions involved students, their teachers, the school environment and the community but not their parents [20, 53]. 2 (9%) studies focused on interventions that involved only students, without the engagement of their parents and teachers, the school environment and the community [50, 57]. 4 (18.2%) trials involved students and their teachers, but not their parents, the school environment and the community [54, 58, 59, 60]. Finally, 1 (1.4%) study involved students, their parents, the school environment and the community, but not their teachers [44 (study 1)], and 1 (1.4%) study involved students and the school environment but not their parents, their teachers and the community [45].

Table 2a.

Outcomes and tools: “Life Skills Training” (LST) programs measuring emotional and social skills and/or healthy behavior outcomes.


Study Outcomes Mediators or Covariates Measures/Tools
Buhler et al., [46] Healthy behaviors:
- tobacco and alcohol’ use
- affinity toward tobacco and alcohol
Emotional and social skills:
- Knowledge about life skills and life skills behaviors (self-awareness and empathy, creative and critical thinking, communication and interpersonal relationships,decision making and problem solving and coping with stress and emotions + refusal assertiveness).
not standardized scales:
- respondents were asked whether they had ever used tobacco or alcohol (response format: ‘yes, several times’, ‘yes, I tried’ and ‘no’) and whether they had used it in the past 30 days. Current users reported frequency of use during the past 30 days and amount of use per occasion. The amount of alcohol use per occasion was reported in a free format.
Subsequently, data were dichotomized into ‘abuse’ and ‘no use/experimental use’.
- “Tobacco and Alcohol Distance” are two scales developed to predict later substance use behavior (not standardized).
- “Life Skills Behaviors”: 33 items scale + 3 items taken from Botvins’ questionnaire indicating refusal assertiveness (developed by authors)
Eisen et al., [42]
- see also:
Eisen et al., [68]
Healthy behaviors:
- tobacco, alcohol and illega/illicitl drugs use
Emotional and social skills:
- behavioral intention to use tobacco, alcohol, marijuana and cocaine in the next 3 months
- social influences
- interpersonal perceptions
- perception of harmful effects of drugs
- communication skills
- self efficacy
- sensation-seeking
- sociodemographics (gender, age, family structure/household composition, race/ethnicity) - 3 cigarette smoking questions estabilished by the National Cancer Institute as standard items
standard questions adapted from Monitoring the Future (MTF) study for alcohol, marijuana, cocaine and other illegal/illicit drugs use:
- item from (MTF) for behavioral intention to use
- standard questions on normative beliefs about the prevalence of substance use by a best friend, friend in general and same grade-peer
- 3 items scale on whether using alcohol, cigarettes and marijuana make it easier to “fit in”.
- 3 items scales focusing on wheather alcohol/being drinking, smoking/marijuana, cocaine help or harm ones’ health, ability to relax, and popularity
- 3 items scales to assess self efficacy around refusing the use of alcohol, cicarettes/marijuana, cocain in various situations
- 2 items scale for perceived parent monitoring of students’ behaviors
- demographic variables scale
Fitzpatrick et al., [20] Emotional and social skills:
- prosocial behaviour
- emotional and behavioural difficulties
- active coping, support seeking and less use of avoidance
- help-seeking
- students’ views of
school social environment
-Sociodemographics (gender)
- Cut off scores of mental problems (Clinical/Normal)
- The strengths and difficulties questionnaire (SDQ)
- The childrens’ coping strategies checklist (CCSC)
- help-seeking questionnaire (not standardized)
- ‘What is your school like?’ questionnaire (not standardized)
Huang et al., [48] Emotional and social skills:
- Theory of Planned Behaviors’ constructs: (intention not to use illicit drugs; attitude, subjective norm, perceived behavioral control);
- life skills
-questionnaire for Theory of Planned Behaviors’ constructs (not standardized)
- 16 items questionnaire for life skills (not standardized)
Johnson et al., [43] Healthy behaviors:
- Harmfull Legal Products (HLP) use (inhalants, prescription medicines, over-the-counter medications, common household products)
- substance use (tobacco, alcohol, marijuana or hashish
Emotional and social skills:
-Risk factors (Peer Use of HLPs; Peer Normative Beliefs about HLPs);
- Protective factors (Knowledge of Drugs and
- Community/School-Level Characteristics (community population (2006), percentage of White population in the community, poverty rate, average experience level of teachers, number of vandalism incidents, number of enrolled students, number of suspensions and expulsions (across nine possible types), number of school incidents (across nine possible types), rate of in-migration, rate of out-migration, proportion of students eligible for free or reduced-price lunch, and school -questionnaire for tobacco, alcohol, marijuana, inhalants, prescription medicines, and
over-the-counter medications use (taken from Arthur et al., 1998, not standatdized);
- questionnaire for common household products’ use (not standardized);
- 4 items for Peer Use of HLPs (modified from Hansen and McNeal, 1997, not standardized);
- 4 items for Peer Normative
Beliefs about HLPs (modified from Hansen and McNeal, 1997, not standardized);
Consequences of Use; Assertiveness Skills; Cultural Identity); system readiness to implement substance abuse prevention programs;
- School Dynamics (presence in the school for both evidence-based and non-evidence-based prevention programming)
- 7 items for Knowledge of Drugs and Consequences of Use (modified from Gilchrist et al., 1987, not standardized);
- 9 items for Assertiveness Skills (modified from Scheier et al., 1999, not standardized)
- 6 items for Cultural Identity (modified from Gilchrist et al., 1987, not standardized);
- telephone survey of key informants (on average seven per community) from 14 communities (total n=100), constructs from the Community Readiness Model developed by the Tri-Ethnic Center at the University of Colorado (Oetting et al., 1995).
Resnicow et al., [49] Healthy behaviors:
Primary:past month use of cigarettes
Secondary: - frequent cigarettes use (>20 days per month)
- marijuana use;
- beinge drinking
- illicit drug use (cocaine/crack, methaqualone, methamphetamine)
Emotional and social skills:
- perceived harm of ever and regular tobacco, marijuana, and alcohol use
- perceived refusal skills for five substances
- smoking attitudes
- demographics (gender; ethnicity) - binary items (nonuse/use) for each substance and period use (not standardised)
- three-point scale (harm, slight harm, great harm) (not standardised);
- five-point scale (refusal shills (not standardised)
- ten-item neasure (smoking attitudes) (not standardised)
Seal, [50] Healthy behaviors:
- tobacco and drug use
Emotional and social skills:
- knowledge about the health consequences of tobacco and drug ;
- attitudes toward tobacco and drug use prevention
- life skills (refusal, decision-making, problem solving)
- demographics (age, gender, grade) - 17 yes/no questions for knowledge about the health consequences of tobacco and drug use (no standardized);
- 4 point scale for attitudes toward tobacco and drug use prevention (not standardized)
- life skills questionnaire (not standardized);
- tobacco and drug use frequency questionnaire (not standardized)
Walker et al., [51] Healthy behaviors:
- condom use
Emotional and social skills:
- reported sexual activity;
- knowledge and attitudes about HIV and emergency contraception;
- attitudes and confidence about condom use;
- demographics (sex, age) - 93 item questionnaire on knowledge and attitudes about HIV, AIDS, and emergency contraception; sexual experience; use of condoms at first and most recent intercourse. It also asked about tobacco, alcohol, and drug use, compensated sex (exchange of sex for money, goods, or favours), social networks, socioeconomic status, and intention
to continue in school (not standardized).

No study involved students, their parents, their teachers, the school environment and their relevant community simultaneously.

Regarding the effectiveness of the included studies, findings were very heterogeneous about the outcomes assessed by different tools and statistical analyses. Table 3) summarises that Life Skills Training (LST) is generally effective in improving emotional and social skills, and healthy behaviours [20, 32, 42, 43, 44(study 1 and 2), 46, 48-51, 56, 58], as well as other kinds of interventions on emotional and social skills, psychological wellbeing, healthy behaviours, and academic performance, namely the “Gatehouse Project” [52], “Free fruit and vegetables snacks plus Enhanced Nutrition Education” [53], “Zippis’ Friends” [47], “4Rs Social-Emotional Learning Program (Reading, Writing, Respect, Resolution)” [55], “Yoga Ed Program” [57], “Kripalu Yoga” [60], “COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) Program” [59], “PATHS (Positive Adolescents Training through Holistic Social Programmes” [54], “Plan for Success Goal Clarification survey” [45].

Table 3.

Quality features of the studies included.


Study Standardized Measures Follow-up ≥ 6 Months Waves of Data ≥ 2 Academic Year Effectiveness (p < 0.05) Safe Practices 3 at least,
among: Sequency, Active, Focused, Explicit
Whole School Approach levels
Bond et al., [52] YES (anxiety/depressive symptoms)
YES (social interactions)
NO (victimization)
YES (school engagement)
YES (cigarette and alchool use)
NO YES
YES (substance use)
NO (anxiety/depressive
symptoms; social and school relationships)
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (School environment)
NO (Community)
Botvin et al., [32] YES (marijuana, cocaine, inhalants, nonmedical pill use, heroin and other narcotics, hallucinogens use) NO NO YES (marijuana; inhalants; heroin and othe narcotics, hallucinogens use)
NO (cocaine; non medical pill use)
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (School environment)
NO (Community)
Buhler et al., [46] NO (tobacco and alcohol use)
NO (affinity toward tobacco and alcohol)
NO (knowledge about life skills and life skills behaviors; refusal assertiveness)
NO NO YES (nicotine abuse)
NO (alcohol abuse)
YES (tobaco and alcohol affinity)
YES (knowledge skilled behaviors; life skills)
NO (Knowledge unskilled behaviors; life skills deficit)
YES (Knowledge skilled behaviors on all outcomes)
NO (life skills on tobacco and alcohol affinity)
YES (life skills on nicotine abuse in smokers at baseline)
YES YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Eisen et al., [42]
- see also:
Eisen et al., [68]
YES (tobacco, alcohol, illegal/illicit drugs use)
YES (intention to use substance)
YES ( social influences)
YES (interpersonal perceptions)
YES (comunication skills)
YES (self efficacy)
YES (sensation-seeking)
NO NO YES (marijuana’ lifetime and 30-day use)
NO (lifetime and 30-day use of cigarettes, other illicit substances, alcohol; last 30-day binge drinking)
YES (refusal self efficacy for alcohol and marijuana)
NO (intention, perceived harm perceived peer use/close friend for all substance; refusal self efficacy for cigarettes and cocaine)
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Fitzpatrick et al., [20] YES (prosocial behavior; emotional and behavioral difficulties; active coping/less use of avoidance)
NO (help seeking; view of school social environment)
YES NO YES (in the enhanced (EP) intervention whole group for peer problems; at risk EP boys for emotional and behavioral difficulties, hyperactivity and total difficulties)
NO (EP for coping strategies)
YES (in the standard intervention (SP) group for help seeking)
Both EP and SP interventions:
YES
Both EP and SP interventions:
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
YES (Community)
He et al., [53] YES (fruit and vegetable consumption)
YES (knowledge, attitude, liking, self-efficay, intention, willingness, habit, preferences and peer influences toward fruit and vegetables)
NO NO Yes YES (in FFVS+ENE intervention for fruit and vegetables consumption at school)
NO (in FFVS+ENE intervention for fruit and vegetables consumption at home)
YES (in FFVS+ENE intervention for liking toward fruit and vegetables)
YES (adverse outcome in FFVS intervention: unfavorable change in self efficacy, intention and peer influence in vegetable consumption
FFVS+ENE intervention:
YES
FFVS+ENE intervention:
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
YES (Community)
Holen et al., [47] YES (coping strategies)
YES (mental health: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems, prosocial behaviors)
NO NO YES (children and parents for coping strategies: children for oppositional strategies; parents for active and support seeking strategies)
NO (parents and teachers for emotional symptoms; conduct problems; hyperactivity/inattention; peer problems, prosocial behaviors)
YES (teachers for impact of mental health problems)
YES YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Huang et al., [48] NO (intention, attitude, subjective norm, perceived behavioral control about drug use)
NO (life skills)
NO NO YES (in LST group for life skills and attitude, subjective norm, perceived behavioral control, intention about drug use) YES YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Johnson et al., [43] NO (Harmfull Legal Products (HLP) use in the past 30 days: inhalants, prescription medicines, over-the-counter medications, common household products)
NO (substance use in the past 30 days: tobacco, alcohol, marijuana or hashish)
NO (Risk factors: Peer Use of HLPs; Peer Normative Beliefs about HLPs);
NO (Protective factors: Knowledge of Drugs and Consequences of Use; Assertiveness Skills; Cultural Identity);
YES NO YES (harmful legal products, inhalants the most)
NO (tobacco, alcohol, marijuana)
NO (risk and protective factors on substance use)
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Jones et al., [55] YES (Social-Cognitive Processes: hostile attribution biases; aggressive interpersonal negotiation strategies; normative beliefs about aggression)
YES (Social-Emotional Symptomatology: child ADHD symptoms; depressive symptoms; aggressive and prosocial fantasies)
YES (Aggressive and Prosocial Behaviors: child aggression; child social competence)
YES (Academic Performance: academic skills; math and reading achievement; attendance rate)
NO YES YES (social-cognitive processes and social-emotional symptomatology)
YES (aggressive and socially competent behavior)
No (main effect for academic functioning)
YES (chidren at behavioral risk at baseline for academic functioning: maths and reading achievement)
NO (chidren at behavioral risk at baseline for social and emotional skills)
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Khalsha et al., [57] YES (emotional symptoms, school problems, internalizing problems, inattention/hyperactivity, personal adjustment, anxiety, anger control, mania, ego strenght);
YES (mood states);
YES (resilience);
YES (perceived stress);
YES (Self-confidence during Stress);
YES (Life Purpose and Satisfaction)
NO NO YES (anger control, fatigue, resilience)
NO (emotional symptoms, school problems, internalizing problems, inattention/hyperactivity, personal adjustment, anxiety, mania, ego strenght, mood states, self-confidence during stress, life purpose and satisfation)
YES
YES (Students)
NO (Parents)
NO (Teachers)
NO (school environment)
NO (Community)
Melnyk et al., [59] YES (healthy lifestyles behaviors: physical activity)
YES (health grade)
YES (overweight)
YES (BMI)
YES (depressive and anxiety symptoms);
YES (social skills:cooperation, assertion, academic competence);
YES substance use (alcohol, marijuana);
YES academic performance
YES NO YES (physical activity; BMI; social skills: coperation, assertetion, academic performance; health grade; substance use (alcohol); overweight)
NO (substance use: marijuana; anxiety and depressive symptoms)
YES
YES (Students)
NO (Parents)
YES (Teachers)
NO (school environment)
NO (Community)
Noogle et al., [60] Psychosocial Wellbeing:
YES (mood: total mood disturbance, Tension-Anxiety, Depression- Dejection, Anger-Hostility, Vigor-Activity, Fatigue- Inertia, Confusion-Bewilderment);
YES (affect: positive and negative);
YES (perceived stress);
YES (positive psychological attitudes: self-confidence during stress; life purpose and satisfaction)
Self-Regulatory Skills:
YES (Resilience)
YES (Anger expression)
YES (Mindfulness)
NO NO YES (Psychological wellbeing: total mood disturbance and tension/anxiety; negative affect)
NO (Psychological wellbeing: Depression- Dejection, Anger-Hostility, Vigor-Activity, Fatigue- Inertia, Confusion-Bewilderment; positive affect; positive psychological attitudes; perceived stress)
NO (self regulatory skills)
YES
YES (Students)
NO (Parents)
YES (Teachers)
NO (school environment)
NO (Community)
Resnicow et al., [49] NO (past month use of cigarettes)
NO (lifetimie use of cigarettes)
NO (frequent cigarettes use: >20 days per month)
NO (past month marijuana use)
NO (past month beinge drinking)
NO (past month illicit drug use: cocaine/crack, methaqualone, methamphetamine)
NO (perceived harm of ever and regular tobacco, marijuana, and alcohol use)
NO (perceived refusal skills for five substances)
NO (smoking attitudes)
NO NO NO (past month use, lifetime use, frequent use of cicarettes, past month use of marijuana, past month binge drinking, past month use of illicit drug use)
YES (KEEP LEFT for males and females/males Black Africans)
YES (LST for females and females/males“colored”)
NO (for females/males indian and white)
YES (KEEP LEFT for males about past month marijuana use)
YES (KEEP LEFT and LST for females about past month marijuana use)
YES (KEEP LEFT and LST for males about past month bing drinking: adverse outcome)
YES (KEEP LEFT for females about past month illicit drugs)
NO (perceived harm, self-efficacy, drug attitudes)
YES (KEEP LEFT for males about perceiving harm of regular use)
YES (KEEP LEFT for black about perceiving harm of regular use)
YES (LST for black and colored about perceiving harm of regular use)
Both LST and KEEP LEFT interventions:
YES
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Seal, [50] NO (knowledge about the health consequences of tobacco and drug)
NO (attitudes toward tobacco and drug use prevention)
NO (life skills: refusal, decision-making, problem solving)
NO (tobacco and drug use)
YES NO YES (knowledge about the consequence of tobacco and drug; attitudes toward tobacco and drug use prevention; life skills)
NO (tobacco and drug use)
YES
YES (Students)
NO (Parents)
NO (Teachers)
NO (school environment)
NO (Community)
Shek et al. [54]
- see also:
Shek et al.,
[71; 72; 73; 74; 75; 76]
YES (Positive Youth Development: bonding; resilience; social competence; emotional competence; cognitive competence; behavioral competence; moral competence; self-determination; self efficacy; beliefe in the future; clear and positive identity; spirituality; prosocial norms; recognition for positive behavior) YES YES YES (positive self identity, prosocial behavior, recognition of positive behavior)
YES (more stable rate of growth in moral competence and behavioral competence)
YES (students who regarded the program to be helpful in problems behaviors)
YES
YES (Students)
NO (Parents)
YES (Teachers)
NO (school environment)
NO (Community)
Spoth et al.,
study 1 [44]
NO (past year methamphetamine use) YES YES YES (ISFP for past year methanphetamine use)
NO (PDFY for past year methanphetamine use)
Both PDFY and ISFP:
YES
Both PDFY and ISFP:
YES (Students)
YES (Parents)
NO (Teachers)
YES (school environment)
YES (Community)
Spoth et al.,
study 2 [44]
NO (past year and lifetime methamphetamine use) YES YES YES (LST+SFP 10-14 for lifetime use)
YES (LST only for lifetime use)
Both LST and SFP 10-14:
YES
For SFP 10-14 see ISFP in previews row;
LST:
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Spoth et al., [56]
- see also:
Spoth et al.,
[69; 70]
NO (alcohol, cigarettes, marijuana initiation)
NO (monthly frequency of Alcohol, Drunkenness Cigarette Marijuana Use )
NO (more problematic or serious substance use: poly-substance use)
YES YES YES (one or both interventions on all substance initiation and for polysubstance use in higher risk subsamples)
YES (accumulation one or both interventions benefits on outcomes)
Both LST and SFP 10-14:
YES
For SFP 10-14 see ISFP in previews row;
LST:
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Walker et al., [51] NO (condom use, reported sexual
Activity, knowledge and attitudes about HIV and emergency contraception, attitudes and confidence about condom use)
YES NO NO (condom use)
YES (both intervention on knowledge of HIV)
YES (LST + emergency contraception on knowledge of emergency contraception)
YES (both intervention on sexual behaviors)
Both LST and LST + emergency contraception
YES
Both LST and LST + emergency contraception
YES (Students)
NO (Parents)
YES (Teachers)
YES (school environment)
NO (Community)
Werch et al., [45] YES (risk behaviors: alcohol, cigarettes, marijuana consume);
YES (health promotion behaviors: eating habits, exercise, stress management)
YES (personal development behaviors: college and career preparation)
YES (health quality of life)
YES (self-image)
YES (behavior coupling beliefs; perceived peer prevalence and frequency of future comparisons)
NO NO YES (Goal Survey + Career Consultation on alcohol use, marijuana use, exercise, college preparation, career preparation, nutrition habits, behavior coupling) All interventions
YES
All interventions
YES (Students)
NO (Parents)
NO (Teachers)
YES (school environment)
NO (Community)
Young et al., [58] YES Self-reported estimated daily energy expenditure (physical activity),
NO self-reported sedentary
activities (television viewing and computer or Internet use),
YES cardiorespiratory fitness
YES cardiovascular disease risk factors (BMI, waist-hip ratio, waist circumference, blod pressure, total cholesterol level, lipopretein level)
NO NO YES (spending more physical education class time in moderate to vigouros activity)
NO (daily energy expenditure, moderate, hard or very hard intensity expenditure,)
YES (self-reported sedentary activities)
YES (both interventions on cardiorespiratory fitness)
YES
YES (Students)
NO (Parents)
YES (Teachers)
NO (school environment)
NO (Community)

DISCUSSION

This systematic review reports the main features of universal school-based RCTs aimed to enhance the youths’ emotional and social skills in order to promote their positive development and wellbeing. Furthermore, it shows promising findings about the effectiveness of such interventions on the outcomes considered by the authors.

Table 2c.

Outcomes and tools: Different programs (than LST) on emotional and social skills, psychological wellbeing indicators, healthy behaviors, academic performance outcomes.


Study Outcomes Mediators or Covariates Measures/Tools
Bond et al., [52] Psychological wellbeing indicators
- Mental health status (self reported anxiety/depression);
- social relations (availability of attachments and conflictual relationships);
- victimisation;
- school engagement
Healthy behavior
- substance use
- peers’ substances use;
- family structure (intact; separated/divorced; other circumstances); language other than English spoken at home; cowntry of birth (Australia vs other); parents’ smoking cigarettes and/or drinking alcohol;
- gender
- Clinical Interview Schedule-Revised (CIS-R)
- Interview Schedule for Social Interaction
- 4 items addressing types of recent victimisation;
- School Engagement Scale;
- set of questions developed by the Center for Adoleschent Health (Patton et al., 1995) to rate current smoking and drinking;
- 7 days diary for students who had smoking tobacco in the past month or drunk alcohol in the past two weeks or used marijuana in the past six months.
He et al., [53] Healthy behavior
- fruit and vegetable consumption
Emotional and social skills
- knowledge, attitude, liking, self-efficay, intention, willingness, habit, preferences and peer influences toward fruit and vegetables
- Pre-Coded 24h Fruit and Vegetable Recall Questionnaire (Haraldsdootir et al., 2005);
- Pro-Children Questionnaire (adapted)
Holen et al., [47] Emotional and social skills
- coping strategies (distraction, social withdrawal, cognitive restructuring, self-criticism, blaming others, problem solving, emotional expression, wishful thinking, social support, resignation)
Psychological wellbeing indicators
- mental health (emotional symptoms, conduct problems, hyperactivity/inattention, perr problems, prosocial behaviors)
- demographics (parents’ socio-economic status (SES); childs’ sex) - Kidcope Questionnaire (Spirito et al., 1988) - children version (7-12 years);
- adaptation of Kidcope questionnaire – adolescent version (administered to parents)
- Strenghts and Difficulties Quationnaire (SDQ), (Goodman, 1997) (parents and teachers form)
Jones et al., [55] Emotional and social skills:
- Social-Cognitive Processes (hostile attribution biases; aggressive interpersonal negotiation strategies; normative beliefs about aggression);
- Aggressive and Prosocial Behaviors (child aggression; child social competence);
Psychological wellbeing indicators
- Social-Emotional Symptomatology (child ADHD symptoms; depressive symptoms; aggressive and prosocial fantasies);
Academic performance:
- academic skills;
- math and reading achievement;
- attendance rate
- household socioeconomic status (SES) risk index (single-parent household; less than high school education; poverty at or below 100% of the federal poverty level; unemployment);
- Community risk;
- Child behavioral risk;
- Children’ sociodemographics (gender; race/ethnicity);
- teacher’ burnout;
- teacher’ experience;
- classroom size
- 2 self-report questionnaires for hostile attribution biases and aggressive interpersonal negotiation strategies (adapted from the Home Interview Questionnaire (Dalhberg et al., 1998; Dodge, 1986)
- Normative beliefs about Aggression Scale (Huesmann & Guerra, 1997) (self report);
- ADHD Symptomatology Scale (Milch et al., 1982) (teacher report) for ADHD symptoms;
- Diagnostic Interview Schedule for Children Predictive Scales (Lucas et al., 2001) (self-report) for depressive symptoms;
- “What I Think” (Rosenfeld et al., 1982) (self-report) for aggressive and prosocial fantasies;
- Behavioral Assessment System for Children (Reynolds & Kamphaus, 1998) (teacher report) for child aggression and conduct problems
- Social Competence Scale (CPPRG, 1999) (teacher report) for child social competence;
- 9 items adapted from the Early Childhood Longitudinal Study, Kindergarten (ECLS-K) for academic skills;
- New York State standardized assessment of math and reading achievement (standard reports);
- NYC Department of Education standard reports for attendance rate (school years 2004-2005; 2005-2006) ;
- parents’ report for SES risk index
- parent report on the Community Risk and Resources Questionnaire (Forehand et al., 2000);
- Teacher Burnout Inventory (Maslach et al., 1996)
Khalsha et al., [57] Psychological wellbeing indicators
- personality (emotional symptoms, school problems, internalizing problems, inattention/hyperactivity, personal adjustment, anxiety, anger control, mania, ego strenght);
- mood states;
Emotional and social skills:
- resilience;
- perceived stress;
- Self-confidence during Stress;
- Life Purpose and Satisfaction
- Self-Report of Personality (SRP) version of the Behavior assessment Survey for Children Version 2 (BASC-2)
- Profile of Mood States short form (POMS-SF);
- Resilience Scale (RS);
- Perceived Stress Scale (PSS);
- Inventory of Positive Psychological Attitudes-32R (IPPA)
Melnik et al.,
[59]
healthy behaviors
- phisical activity
- substance use (alcohol, marijuana);
academic performance
Psychological and physical wellbeing indicators
- depressive and anxiety symptoms;
- health grade
- overweight
- BMI
Emotional and social skills
- social skills (cooperation, assertion, academic competence);
- acculturation - pedometer steps;
- Healthy Lifestyles Behavior Scale (HLBS) (self report);
- Heights and Weights;
- Beck Youth Inventory II (self report);
- Social Skills Rating System (SSRS) (teacher report)
- questions about substances use from Youth Risk behavior Survey (self report);
- students’ health course grade (school records);
- acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA) (self report)
Noogle et al., [60] Psychosocial Wellbeing indicators
- mood (Tension-Anxiety, Depression-Dejection, Anger-Hostility, Vigor-Activity, Fatigue- Inertia, Confusion-Bewilderment);
- affect (positive and negative);
Emotional and social skills
- perceived stress;
- positive psychological attitudes (self-confidence during stress; life purpose and satisfaction)
- Resilience;
- Anger expression
- Mindfulness
- Profile of mood States-Short Form (POMS-SF);
- Positive and Negative Affect Schedule for children (PANAS-C);
- Perceived Stress Scale (PSS)
- Inventory of Positive Psychological Attitudes-32R (IPPA)
- 25 item Resilience Scele (RS);
- State-Trait Anger Expression Inventory-2 (STAXI-2);
- Child Acceptance and Mindfulness Measure (CAMM)
Shek et al. [54]
- see also: Shek et al., [71; 72; 73; 74; 75; 76]
Emotional and social skills:
- bonding (BO);
- resilience (RE);
- social competence (SC);
- emotional competence (EC);
- cognitive competence (CC);
- behavioral competence (BC);
- moral competence (MC);
- self-determination (SD);
- self efficacy (SE);
- beliefe in the future (BF);
- clear and positive identity (CPI);
- spirituality (S);
- prosocial norms (PN);
- recognition for positive behavior (RPB)
- positive youth development (CPYDS-12) (bonding + resilience + social competence + emotional competence + cognitive competence + moral competence + self-efficacy + beliefs in the future + clear and positive identity + spititual + prosocial involvement + recognition for positive behavior);
- Psychosocial competence and strenghts (CPYDS-10) (resilience + social competence + emotional competence + cognitive competence + behavioral competence + moral competence + self determination + self efficacy + beliefs about the future + clear and positive identity);
- Behavioral competence and Moral competence (CYPDS-2);
- Cognitive-Behavioral Competence (CBC);
- Prosocial Attitude (PA);
- Positive Identity (PID);
- General Positive Youth Development Qualities (GPYDQ).
- Chinese Positive Youth Development Scale (CPYDS)
Werch et al., [45] Healthy behaviors:
- alcohol, cigarettes, marijuana consume;
- eating habits
- exercise,
Emotional and social skills
- stress management
- health quality of life
- self-image
- behavior coupling beliefs
- perceived peer prevalence and frequency of future comparisons
Academic performance
- personal development behaviors (college and career preparation)
- Personal Development and Health Survey 7

The studies included went openly beyond a problem-focused approach to embrace a more positive view of mental health to promote youths’ wellbeing [1, 3, 8]. Collectively, these findings build on the positive results reported by other systematic reviews examining the promotion of positive development and wellbeing of children and teenagers in schools [9-12, 18, 22, 41].

Due to the variety in age/school grade of participants, characteristics of intervention and control groups, duration of programs and follow-up, assessed outcome and relevant tools, a direct comparison among the included studies is very difficult.

Overall, the interventions targeted social and emotional competences and attitudes about oneself, the others and the school. The main aim of these interventions was enhancing these skills and/or the healthy behaviours of the students (i.e. to prevent substance abuse) and/or promoting their psychological wellbeing (i.e. regarding mood and affects) and/or improving their academic performance.

While only small percentages of the included studies collected data at ≥ 6 month follow-up after the end of the intervention (40.9%) or during at least two academic years by repeated measures (27.3%), the effects remained statistically significant by the time they were assessed. However, many included studies compared the groups exposed to such interventions to groups exposed to any kind of intervention. or treatment as usual (i.e. curricular health education).

This systematic review differs in emphasis from previous research syntheses by including exclusively universal school-based RCTs aimed to test the effectiveness of interventions focused on emotional and social skills improvement to promote the youths’ wellbeing.

Noteworthy, among the texts excluded from this review, 15 papers described RCTs in this field with data analysis still pending. However, even if the researchers are increasingly attempting to conduct studies with rigorous experimental design, there is a range of practical and human impediments to using a “full” controlled randomisation in the school setting, such as objections from line staff and parents who feel that random assignment excludes some children having the same needs, and issues of access to parental consent or permission [12].

Furthermore, the studies included in this review aimed at a whole-school approach that promote “bottom-up” principles such as empowerment, autonomy, participation [3], and non-prescriptive and flexible practices that emphasize the need of end-user involvement. These features could contrast basically with manualized approaches that contain strict requirements for program fidelity, hard outcomes and measurable changes [10].

In this sense, the effectiveness of the RCTs included in this review may be relative in statistical terms, but it represents effects of outcomes that are important in the real world, are relatively large and similar to, or higher in, magnitude than those obtained by many other established preventive and treatment interventions in the fields of social sciences and medicine [9, 22, 61].

As Weare et al. [10] already pointed out, many reviews of school-based interventions state that the acquisition of social and emotional skills was associated with a wide range of important health outcomes in the youth, including: positive youth development, character education, a reduction in depression and anxiety, conduct disorders, violence, bullying, conflict, and anger. This amount of data allows considering emotional and social skills improvement as an outcome in itself [10].

In this review, emotional and social skills were assessed as unique outcomes in two studies implementing Life Skills Training (LST) specifically [20, 48], and in one study implementing a different program than LST [55]. Three more studies implementing different programs than LST assessed emotional and social skills as outcomes together with psychological wellbeing indicators [47, 52, 57, 60].

On the other hand, 5 out the 13 studies implementing LST evaluated only healthy behavior outcomes without assessing emotional and social skills as neither outcomes or mediators 32; 44 (study 1 and 2); 56; 58]. This choice could be due in part to the amount of evidence about the above mentioned association between life skills and health outcome improvement. At the same time, it marks a series of methodological issues and limits.

While healthy behaviors and academic performance are relatively easy to assess by specific indicators, some constructs such as positive youth development, the youths’ psychological wellbeing and life skills are difficult to define univocally [8; 12]. Not surprisingly, many studies included in this review use no standardised measures, because their authors developed ad hoc measures to assess emotional and social skills and psychological wellbeing, as outcomes or mediators. This is probably due in part to the uncertain definition of these constructs, but also to the lack of studies aiming to develop and validate instruments that may assess the life skills and psychological wellbeing of the youth [9, 10, 12, 18, 41, 62].

Regarding the included studies that use standard tools, these constructs were measured by a single tool for each skill (i.e. Resilience Scale [63] to assess resilience in the study by Khalsha et al. [57]; Kidcope Questionnaire [64] to assess coping strategies in the study by Holen et al. [47]). Noteworthy some included studies [46, 54] attempted to build some tools to assess life skills or positive youth development but showed some limits, mainly concerning the validity tests on such tools (i.e. internal reliability and construct validity).

In this sense, the effectiveness of Life Skills Training (LST) as well as of other kinds of intervention on outcomes such as healthy lifestyle behaviours, academic performance, psychological wellbeing, with or without assessment of emotional and social skills reliably (see Tables 1b), 2b), and 3), is a critical point. Other variables than life skills could affect findings. These issues regard also those studies where the mediation effects of social and emotional skills on the main outcomes were postulated but not tested.

Table 2b.

Outcomes and tools: “Life Skills Training” (LST) programs measuring only healthy behavior outcomes.


Study Outcomes Mediators or Covariates Measures/Tools
Botvin et al., [32] - cocaine, inhalants, nonmedical pill use, heroin and other narcotics, hallucinogens use
- tobacco, alcohol and marijuana use
tobacco, alcohol and marijuana current use (amount and frequency at baseline) Not standardized scales:
- 8 point scale for tobacco’ frequency use
7 point scale for tobacco’amount use
9 point scale for alcohol frequency use
6 point scale for alcohol amount use
9 point scale for frequency of getting drunk
9 point scale for frequency of marijuana use
Spoth et al., [56]
- see also:
Spoth et al.,
[69; 70]
- alcohol initiation (AI);
- cigarette initiation (CI); - marijuana initiation (MI);
- monthly frequency of Alcohol Use (AF);
- monthly frequency of Cigarette Use (CF);
- monthly frequency of Drunkenness(DF);
- monthly frequency of Marijuana Use (MF);
- more problematic or serious substance use (poly-substance use)
- Sociodemographics (gender; ethnicity; living with both biological parents; free or reduced-price school lunch) - Substance Initiation Index – 3 item (not standardized);
- 4 item for substance frequency use (not standardized);
- Monthly poly-substance use, 3 items (MPU) index (not standardized);
- advanced poly-substance use (APU) index, 5 items (not standardized)
Spoth et al.,
study 1 [44]
- methamphetamine use 1 item (not standardized)
Spoth et al.,
study 2 [44]
- methamphetamine use 2 item (not standardized)
Young et al., [58] - Self-reported estimated daily energy expenditure (physical activity),
- self-reported sedentary
activities (television viewing and computer or Internet use),
- cardiorespiratory fitness
- cardiovascular disease risk factors (BMI, waist-hip ratio, waist circumference, blod pressure, total cholesterol level, lipopretein level.
- 7-day Physical Activity Recall;
- submaximal 3-stage step test for cardiorespiratory fitness;
- selected outcome from a questionnaire for sedentary activities (not standardized)
- standard methods for height, weight, waist and hip circumference, blood pressure,
- venose blood test for total cholesterol and lipoprotein
Table 1b.

“Life Skills Training” (LST) programs measuring only healthy behavior outcomes.


Study Country Interventions (Focus; Sample Size) Controls (Focus; Sample Size) Students’ Population Size Students’ Age/Grade at Baseline Duration and Assessment Timeline
Botvin et al., [32] USA Life Skills Training (program to promote life skills and prevent drug use; N=302) Treatment as usual (Not defined; N=145) N=447 7 gade 3 academic years (intervention in the first academic year + booster in second and third academic years) (pre-post)
Spoth et al., [56]
- see also: Spoth et al., [69; 70]
USA - Iowa Strenghtening Families Program (ISFP) (ISFP ia a program to enhance parental skills in nurturing, limit setting, and communication, as well as youth prosocial and peer resistance skills to reduce youth substance use and other problems behaviors; N = 148)
- Preparing for the Drugs Free Years(PDFY) (Family competency training program to enhance protective parent-child interactions and to reduce childrens’ risk for early substance use initiation; N = 140)
Minimal contact (mailed reading materials; N = 156) N = 444 6 grade (baseline) 1 academic year (ISFP duration was 7 sessions (each 2 hours); PDFY duration was 5 sessions (each 2 hours)) (pre + 6.5 years past baseline (follow-up)
Spoth et al., study 1 [44] USA - Life Skills Training (LST) + Strenghtening Families Program for parents and youth 10-14 (SFP 10-14) (LST ia a program to promote skills development and to provide knowledge to avoid substance use; SFP 10-14 ia a program to enhance parental skills in nurturing, limit setting, and communication, as well as youth prosocial and peer resistance skills to reduce youth substance use and other problems behaviors; N = 189);
-Life Skills Training (LST ) only ; N = 208)
Minimal contact (mailed reading materials; N = 196) N = 593 6 grade (baseline) 2 academic years ((LST duration was 15 session in 7 grade + 5 booster sessions taugh 1 year later; SFP 10-14 duration was 7 consecutive weeks when youth were in 7 grade + 4 booster session taugh 1 year later) (pre + 4.5 years past baseline (1 follow-up) + 5.5 years past baseline (2 follow-up)
Spoth et al., study 2 [44] USA - Life Skills Training (LST) + Strenghtening Families Program for parents and youth 10-14 (SFP 10-14) (LST ia a program to promote skills development and to provide knowledge to avoid substance use; SFP 10-14 ia a program to enhance parental skills in nurturing, limit setting, and communication, as well as youth prosocial and peer resistance skills to reduce youth substance use and other problems behaviors; N = 543);
-Life Skills Training (LST ) only ; N = 622)
Minimal contact (mailed reading materials; N = 489) N = 1677 7 grade (baseline) 2 academic years (LST duration was 15 session in 7 grade + 5 booster sessions in 8 grade; SFP 10-14 duration was 7 consecutive weeks when youth were in 7 grade + 4 booster session while youth were in 8 rade) (pre + 5 repeted measures during 8-12 grade (post and follow-up)
Young et al., [58] USA -Life Skills Training + standard physical education (program to enhance decision making about the personal benefits of a physically active lifestyle, develop problem-
solving skills, and obtain support from others + school- standard physical education; N = 116)
- School physical education (Standard physical education curriculum in which students were
taught skills in individual and team sports; N =.105)
N = 221 9 grader 1 academic year (pre-post)

Another important finding of the current review is that in most of the included studies, classroom teachers effectively conducted programs to enhance their students’ emotional and social skills and promote their wellbeing. Only in two included studies was the intervention implemented by external personnel, specialized in yoga techniques [57] and career coaching [45]. Therefore, this kind of interventions can be part of the routine educational practices and require external specialized personnel for teachers’ training only.

Furthermore, the programs addressed to enhance the emotional and social skills of the young and promote their wellbeing are effective at all educational levels (elementary, middle, and high school).

As already emphasized by other authors [9, 10, 12, 18, 41], the SAFE practices (Sequential, Active, Focused, Explicit) and a whole-school approach moderate positive student’s outcomes and distinguish evidence-based interventions in the school setting.

In this review, all the included studies contained no less than three SAFE practices considered as dichotomous variables “present/absent”. Even if it could be preferable to evaluate SAFE practices as continuous variables [9, 65], we did not examine them this way due to the lack of information in the included study reports. Further research is needed to establish which SAFE practice impacts specifically on student outcomes, especially on their emotional and social skills. Some SAFE practices, in fact, may be more important than others depending on the nature and the number of evaluated outcomes, the age of students and their development stage, but also on ecological features, such as the school ethos and environment.

Furthermore, previous research pointed out that to achieve optimal impact, the work on personal skills need to be embedded within a whole-school, multi-component approach which includes changes to school ethos, teacher training, liaison with parents, parenting education, community involvement [10, 18]. Most of the studies included in this review regard multi-component interventions targeted at no less than two of the following subjects: students, parents, teachers, school environment, and community.

However, only three RCTs included in this review [44 (study 1 and 2), 56] involved parents in the interventions tested. In the study 1 by Spoth et al. [44] and in two more included studies [16, 54] also the community was involved. From an ecological and systemic point of view, when interventions in the school setting are combined with efforts to create environmental support and reinforcement from family members, health professionals, other concerned community members, and the media, there is an increased likelihood that students will adopt positive social and health practices [20, 40, 53, 66, 67].

LIMITATIONS

This systematic review was performed by searching in the Pubmed/Medline database only. Other databases, such as PsycInfo/Ovid, could provide more findings about school-based RCTs.

More school-based RCTs could be found by searching among the references of the studies included in the systematic review as well as in the excluded papers, reviews and/or meta-analyses.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] WHO. Mental health action plan 2013-2020. Geneva: WHO Document Production Services 2013.
[2] Lindert J, von Ehrenstein OS, Grashow R, et al. Sexual and physical abuse in childhood is associated with depression and anxiety over the life course: Systematic review and meta-analysis. Int J Public Health 2014; 59(2): 359-72.
[3] WHO. Promoting Health through Schools. Geneva: WHO Technical Report Series 870 1997a.
[4] WHO Regional Office for Europe. Regional guidelines: Development of health-promoting schools: A framework for action. Manila: WHO Regional Office for the Western Pacific 1996.
[5] Carta MG, Kovess V, Hardoy MC, et al. Psychosocial wellbeing and psychiatric care in the European Communities: Analysis of macro indicators Soc Psychiatry Psychiatr Epidemiol 2004; 39(11): 883-92.
[6] Hardoy MC, Carta MG, Marci AR, et al. Exposure to aircraft noise and risk of psychiatric disorder: the Elmas survey Soc Psychiatry Psychiatr Epidemiol 2005; 40(1): 24-6.
[7] Frankenburg W. Early identification of children at risk: Resiliency factors in prediction In: 5th International Conference; 1987; Denver: University of Colorado.
[8] WHO. Life skills education in schools Geneva: WHO/MNH/PSF/937ARev2 1997b.
[9] Durlak JA, Weissberg RP, Dymnicki AB, et al. The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions Child Dev 2011; 82: 405-32.
[10] Weare K, Nind M. Mental health promotion and problem prevention in schools: What does the evidence say?. Health Promot Int 2011; 26(Suppl 1): 29-69.
[11] Stewart-Brown S. What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen: WHO Regional Office for Europe 2006 Available from: http://www.euro.who.int/document/e88185.pdf
[12] Catalano RF, Berglund ML, Ryan J, et al. Positive youth development in the United States: Research findings on evaluations of positive youth development programs Ann Am Acad Pol Soc Sci 2004; 591: 98-124.
[13] Mura G, Rocha NBF, Helmich I, et al. Physical activity interventions in schools for improving lifestyle in European countries. Clin Pract Epidemiol Ment Health 2015; 11: 77-101.
[14] Cossu G, Cantone E, Pintus M, Pintus E, et al. Integrating children with psychiatric problems in the classroom. A systematic review Clin Pract Epidemiol Ment Health 2015; 11: 41-57.
[15] Cantone E, Piras AP, Vellante M, et al. Interventions on bullying and cyberbullying in schools: A systematic review Clin Epidemiol Ment Health 2015; 11: 58-76.
[16] Carta MG, Di Fiandra T, Rampazzo L, et al. Introduction. An overview of international literature on school interventions for promoting children and adolescents’ mental health and well-being Clin Pract Epidemiol Ment Health 2015; 11: 16-20.
[17] Tobler NS, Roona MR, Ochshorn P, et al. School-based adolescent drug prevention programs: 1998 meta-analysis J Prim Prev 2000; 30: 275-336.
[18] Greenberg MT, Weissberg RP, O'Brien MU, et al. Enhancing school-based prevention and youth development through coordinated social, emotional and academic learning Am Psychol 2003; 58(6-7): 466-74.
[19] Weare K, Murray M. Building a sustainable approach to mental health work in schools Int J Ment Health Promot 2004; 6: 53-9.
[20] Fitzpatrick C, Conlon A, Cleary D, et al. Enhancing the mental health promotion component of a health and personal development programme in Irish schools Adv Sch Ment Health Promot 2013; 6(2): 122-38.
[21] Bond LA, Hauf AMC. Taking stock and putting stock in primary prevention: characteristics of effective programs J Prim Prev 2004; 24: 199-221.
[22] Durlak JA, Wells AM. Primary prevention mental health programs for children and adolescents: A meta-analytic review Am J Community Psychol 1997; 25: 115-52.
[23] Dusenbury L, Falco M. Eleven components of effective drug abuse prevention curricula J Sch Health 1995; 65: 420-5.
[24] Thomas A, Grimes J, Eds. Gresham FM. Best practices in social skills training In: Thomas A, Grimes J, Eds. Best practices in school psychology. 3rd ed. Washington DC: National Association of School Psychologists 1995; pp. 1021-30.
[25] Bradshaw CP, Brown JS, Hamilton SF. Bridging positive youth development and mental health services for youth with serious behaviour problems Child Youth Care Forum 2008; 37: 209-6.
[26] Bradshaw CP, Goldweber A, Fishbein D, Greenberg MT. Infusing developmental neuroscience into school-based preventive interventions: implications and future directions. J Adolesc Health 2012; 51(Suppl 2): 41-7.
[27] Hamilton M, Hamilton S. The youth development handbook: Coming of age in American communities. Thousand Oaks, CA: Sage Publications 2004.
[28] Damon W, Bonk KC, Menon J. Youth sense of purpose What are the key indicators of positive youth development? A innovative session Meeting of the Society for Research on Adolescence, Baltimore: Maryland 2004.
[29] Foxcroft DR, Tsertsvadze A. Universal school-based prevention programs for alcohol misuse in young people Cochrane Database Syst Rev 2011; 11(5): CD009113.
[30] Hansen WB. School-based substance abuse prevention: A review of the state of the art in curriculum, 1980-1990 Health Educ Res 1992; 7(3): 403-30.
[31] Yankah E, Aggleton P. Effects and effectiveness of life skills education for HIV prevention in young people AIDS Educ Prev 2008; 20(6): 465-85.
[32] Botvin GJ, Griffin KW, Diaz T, et al. Preventing illicit drug use in adolescents: Long-term follow-up data from a randomized control trial of a school population Addict Behav 2000; 25(5): 769-4.
[33] Botvin GJ, Baker E, Dusenbury L, et al. Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population J Am Med Assoc 1995; 273(14): 1106-2.
[34] Pentz MA, Dwyer JH, MacKinnon DP, et al. A multi-community trial for primary prevention of adolescent drug abuse J Am Med Assoc 1989; 261: 3259-66.
[35] Elias MJ, Zins JE, Weissberg RP, et al. Promoting social and emotional learning: Guidelines for educators. Alexandria, VA: Association for Supervision and Curriculum Development 1997.
[36] Benson PL. All kids are our kids: What communities must do to raise caring and responsible children and adolescents. 2nd ed. San Francisco: Jossey-Bass 2006.
[37] Guerra NG, Bradshaw CP. Linking the prevention of problem behaviors and positive youth development: Core competencies for positive youth development and risk prevention. New Dir Child Adolesc Dev 2008; 122: 1-17.
[38] Weissberg RP, Kumpfer K, Seligman MEP. Prevention that works for children and youth: An introduction Am Psychol 2003; 58: 425-32.
[39] Collaborative for academic, social, and emotional learning safe and sound: An educational leader’s guide to evidence-based social and emotional learning (SEL) programs. Chicago, IL: Illinois Edition 2005.
[40] Greenberg MT, Domitrovich CE, Bumbarger B. The prevention of mental disorders in school-aged children: Current state of the field. Prev Treat 2001; 4: 1-59.
[41] Greenberg MT. Current and future challenges in school-based prevention: the researcher perspective. Prev Sci 2004; 5(1): 5-13.
[42] Eisen M, Zellman GL, Murray DM. Evaluating the lions-quest "skills for adolescence" drug education program. Second-year behavior outcomes Addict Behav 2003; 28(5): 883-97.
[43] Johnson KW, Shamblen SR, Ogilvie KA, et al. Preventing youths' use of inhalants and other harmful legal products in frontier Alaskan communities: A randomized trial Prev Sci 2009; 10(4): 298-312.
[44] Spoth RL, Clair S, Shin C, Redmond C. Long-term effects of universal preventive interventions on methamphetamine use among adolescents Arch Pediatr Adolesc Med 2006; 160(9): 876-2.
[45] Werch CE, Bian H, Moore MJ, et al. Brief multiple behavior health interventions for older adolescents Am J Health Promot 2008; 23(2): 92-6.
[46] Bühler A, Schröder E, Silbereisen RK. The role of life skills promotion in substance abuse prevention: A mediation analysis. Health Educ Res 2008; 23(4): 621-32.
[47] Holen S, Waaktaar T, Lervag A, Ystgaard M. The effectiveness of a universal school based programme on coping and mental health: A randomized, controlled study of Zippys’ Friend. Educ Psychol 2012; 32(5): 657-77.
[48] Huang CM, Chien LY, Cheng CF, Guo JL. Integrating life skills into a theory-based drug-use prevention program: Effectiveness among junior high students in Taiwan J Sch Health 2012; 82(7): 328-5.
[49] Resnicow K, Reddy SP, James S, et al. Comparison of two school-based smoking prevention programs among South African high school students: Results of a randomized trial. Ann Behav Med 2008; 36(3): 231-43.
[50] Seal N. Preventing tobacco and drug use among Thai high school students through life skills training Nurs Health Sci 2006; 8(3): 164-8.
[51] Walker D, Gutierrez JP, Torres P, Bertozzi SM. HIV prevention in Mexican schools: Prospective randomised evaluation of intervention BMJ 2006; 332(7551): 1189-94.
[52] Bond L, Patton G, Glover S, et al. The gatehouse project: Can a multilevel school intervention affect emotional wellbeing and health risk behaviours?. J Epidemiol Community Health 2004; 58(12): 997-1003.
[53] He M, Beynon C, Sangster Bouck M, et al. Impact evaluation of the Northern Fruit and Vegetable Pilot Programme - a cluster-randomised controlled trial. Public Health Nutr 2009; 12(11): 2199-08.
[54] Shek DT, Ma CM. Impact of the Project P.A.T.H.S. in the junior secondary school years: objective outcome evaluation based on eight waves of longitudinal data Sci World J 2012; 2012: 170345.
[55] Jones SM, Brown JL, Lawrence AJ. Two-year impacts of a universal school-based social-emotional and literacy intervention: An experiment in translational developmental research. Child Dev 2011; 82(2): 533-4.
[56] Spoth RL, Randall GK, Trudeau L, et al. Substance use outcomes 51/2 years past baseline for partnership-based, family-school preventive interventions Drug Alcohol Depend 2008; 96(1-2): 57-68.
[57] Khalsa SB, Hickey-Schultz L, Cohen D, et al. Evaluation of the mental health benefits of yoga in a secondary school: A preliminary randomized controlled trial J Behav Health Serv Res 2012; 39(1): 80-90.
[58] Young DR, Phillips JA, Yu T, Haythornthwaite JA. Effects of a life skills intervention for increasing physical activity in adolescent girls. Arch Pediatr Adolesc Med 2006; 160(12): 1255-61.
[59] Melnyk BM, Jacobson D, Kelly S, et al. Promoting healthy lifestyles in high school adolescents: A randomized controlled trial Am J Prev Med 2013; 45(4): 407-15.
[60] Noggle JJ, Steiner NJ, Minami T, Khalsa SB. Benefits of yoga for psychosocial well-being in a US high school curriculum: A preliminary randomized controlled trial. J Dev Behav Pediatr 2012; 33(3): 193-201.
[61] Stage SA, Quiroz DR. A meta-analysis of interventions to decrease disruptive classroom behaviour in public education settings Sch Psychol Rev 1997; 26: 333-68.
[62] Dirks MA, Treat TA, Weersing VR. Integrating theoretical, measurement, and intervention models of youth social competence Clin Psychol Rev 2007; 27: 327-47.
[63] Wagnild GM, Young HM. Development and psychometric evaluation of the resilience scale J Nurs Meas 1993; 1: 165-78.
[64] Spirito A, Stark LJ, Williams C. Development of a brief coping checklist for use with pediatric populations J Pediatr Psychol 1988; 13(4): 555-74.
[65] Pechman EM, Russell CA, Birmingham J. Out-of-school time (OST) observation instrument: Re-port of the validation study. Washington, DC: Policy Studies Associates, Inc 2008.
[66] Osher D, Dwyer K, Jackson S. Safe, supportive and successful schools, step by step. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services 2002.
[67] Weissberg RP, Greenberg MT. School and community competence- enhancement and prevention programs In: Siegel IE, Renninger KA, Eds. Handbook of child psychology Child psychology in practice 5th ed. 1998; 4: 877954.
[68] Eisen M, Zellman GL, Massett HA, Murray DM. Evaluating the lions-quest "skills for adolescence" drug education program: first-year behavior outcomes Addict Behav 2002; 27(4): 619-32.
[69] Spoth RL, Redmond C, Trudeau L, Shin C. Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs Psychol Addict Behav 2002; 16(2): 129-34.
[70] Spoth R, Randall GK, Redmond C, Shin C. Randomized study of combined universal family and school preventive interventions: Patterns of long-term effects on initiation, regular use and weekly drunkenness Psychol Addict Behav 2005; 19: 372-81.
[71] Shek DT, Siu AMH, Lee TY, et al. Effectiveness of the tier 1 program of project P.A.T.H.S.: Objective outcome evaluation based on a randomized group trial Sci World J 2008; 8: 4-12.
[72] Shek DT, Sun RCF. Effectiveness of the tier 1 program of project P.A.T.H.S.: Findings based on three years of program implementation Sci World J 2010; 10: 1509-9.
[73] Shek DT. Objective outcome evaluation of the project P.A.T.H.S. in Hong Kong: findings based on individual growth curve models Sci World J 2010; 10: 182-91.
[74] Shek DT, Ma CM. Impact of the project P.A.T.H.S. in the junior secondary school years: Individual growth curve analyses Sci World J 2011; 10: 253-66.
[75] Shek DT, Yu L. Prevention of adolescent problem behavior: Longitudinal impact of the project P.A.T.H.S. in Hong Kong Sci World J 2011; 11: 546-67.
[76] Shek DT, Ma CM. Impact of project P.A.T.H.S. on adolescent developmental outcomes in Hong Kong: Findings based on seven waves of data Int J Adolesc Med Health 2012; 24(3): 231-44.