Effectiveness of universal school-based mindfulness training compared with normal school provision on teacher mental health and school climate: results of the MYRIAD cluster randomised controlled trial

BACKGROUND

Education is broader than academic teaching. It includes teaching students social-emotional skills both directly and indirectly through a positive school climate.

OBJECTIVE

To evaluate if a universal school-based mindfulness training (SBMT) enhances teacher mental health and school climate.

METHODS

The My Resilience in Adolescence parallel group, cluster randomised controlled trial (registration: ISRCTN86619085; funding: Wellcome Trust (WT104908/Z/14/Z, WT107496/Z/15/Z)) recruited 85 schools (679 teachers) delivering social and emotional teaching across the UK. Schools (clusters) were randomised 1:1 to either continue this provision (teaching as usual (TAU)) or include universal SBMT. Data on teacher mental health and school climate were collected at prerandomisation, postpersonal mindfulness and SBMT teacher training, after delivering SBMT to students, and at 1-year follow-up.

FINDING

Schools were recruited in academic years 2016/2017 and 2017/2018. Primary analysis (SBMT: 43 schools/362 teachers; TAU: 41 schools/310 teachers) showed that after delivering SBMT to students, SBMT versus TAU enhanced teachers' mental health (burnout) and school climate. Adjusted standardised mean differences (SBMT minus TAU) were: exhaustion (-0.22; 95% CI -0.38 to -0.05); personal accomplishment (-0.21; -0.41, -0.02); school leadership (0.24; 0.04, 0.44); and respectful climate (0.26; 0.06, 0.47). Effects on burnout were not significant at 1-year follow-up. Effects on school climate were maintained only for respectful climate. No SBMT-related serious adverse events were reported.

CONCLUSIONS

SBMT supports short-term changes in teacher burnout and school climate. Further work is required to explore how best to sustain improvements.

CLINICAL IMPLICATIONS

SBMT has limited effects on teachers' mental and school climate. Innovative approaches to support and preserve teachers' mental health and school climate are needed.

School-based mindfulness training in early adolescence: what works, for whom and how in the MYRIAD trial?

BACKGROUND

Preventing mental health problems in early adolescence is a priority. School-based mindfulness training (SBMT) is an approach with mixed evidence.

OBJECTIVES

To explore for whom SBMT does/does not work and what influences outcomes.

METHODS

The My Resilience in Adolescence was a parallel-group, cluster randomised controlled trial (K=84 secondary schools; n=8376 students, age: 11-13) recruiting schools that provided standard social-emotional learning. Schools were randomised 1:1 to continue this provision (control/teaching as usual (TAU)), and/or to offer SBMT ('.b' (intervention)). Risk of depression, social-emotional-behavioural functioning and well-being were measured at baseline, preintervention, post intervention and 1 year follow-up. Hypothesised moderators, implementation factors and mediators were analysed using mixed effects linear regressions, instrumental variable methods and path analysis.

FINDINGS

SBMT versus TAU resulted in worse scores on risk of depression and well-being in students at risk of mental health problems both at post intervention and 1-year follow-up, but differences were small and not clinically relevant. Higher dose and reach were associated with worse social-emotional-behavioural functioning at postintervention. No implementation factors were associated with outcomes at 1-year follow-up. Pregains-postgains in mindfulness skills and executive function predicted better outcomes at 1-year follow-up, but the SBMT was unsuccessful to teach these skills with clinical relevance.SBMT as delivered in this trial is not indicated as a universal intervention. Moreover, it may be contraindicated for students with existing/emerging mental health symptoms.

CLINICAL IMPLICATIONS

Universal SBMT is not recommended in this format in early adolescence. Future research should explore social-emotional learning programmes adapted to the unique needs of young people.

Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial

BACKGROUND

Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health.

OBJECTIVE

The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU).

METHODS

MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11-14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.

FINDINGS

Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI -0.05 to 0.06) for risk for depression; 0.02 (-0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (-0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed.

CONCLUSIONS

Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence.

CLINICAL IMPLICATIONS

There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors.

TRIAL REGISTRATION

Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).

Teachers' views on the acceptability and implementation of the Incredible Years® Teacher Classroom Management programme in English (UK) primary schools from the STARS trial

Background

The Incredible Years^® (IY) Teacher Classroom Management (TCM) programme may reduce disruptive behaviour in the classroom and improve child and teacher mental health; however, few studies have considered how acceptable TCM is to teachers or what facilitators and barriers there are to its implementation.

Aims

In this paper we examine the acceptability of the full 6‐day TCM programme and teachers’ perceived barriers and facilitators to implementation in the English (UK) primary school context.

Sample

Forty‐four English (UK) primary school teachers who attended the TCM programme as part of the STARS trial.

Methods

We completed focus groups and telephone interviews with participating teachers 2 months after they completed the TCM programme. Thematic analysis was used to examine the data, and a framework approach was applied to organize and summarize themes.

Results

Teachers liked the structure of the course, the peer group learning environment, delivery methods, and the opportunity to reflect outside the classroom on their practice. They reported that the video clips used lacked cultural relevance and highlighted the importance of group leadership style. Perceived facilitators to implementation included an understanding of the theory underpinning TCM and adaptability of the TCM strategies. Barriers included perceived gaps in the course content in relation to challenging behaviour, applying strategies with older children and the school context within which teachers were working.

Conclusion

Our findings suggest high levels of acceptability to TCM overall, but also highlight the need for a whole school approach to combat potential barriers to implementation.

Teachers' perceptions of the impact of the Incredible Years® Teacher Classroom Management programme on their practice and on the social and emotional development of their pupils

BACKGROUND

The Incredible Years^® (IY) Teacher Classroom Management (TCM) programme may be an effective way to reduce teacher stress levels, improve child behaviour, and promote positive socio-emotional development. However, few studies have considered what teachers think of the course and how it might work.

AIMS

In this paper, we examine teachers' perceptions of the impact of the TCM programme and how it might work in the classroom.

SAMPLE(S)

Forty-four UK primary school teachers who attended the TCM programme as part of the STARS trial (Ford et al., 2018, Psychol. Med., 49, 828).

METHODS

Focus groups and interviews were held with teachers two months after completing the TCM programme. Thematic analysis (Braun & Clarke, 2006, Qual. Res. Psychol., 3, 77) was employed to explore the subsequent data.

RESULTS

Three main themes were identified: impact on the teacher; on children; and on parent-teacher relationships. Impact on the teacher included a positive change in their ethos. Teachers reported being more able to see things from the child's perspective; placing a greater focus on building positive relationships; thinking before responding; feeling calmer, more confident, and in control; and employing strategies to create positive interactions with children. Teachers felt this had had a positive impact on their pupils' development and relationships with parents. Feedback on whether or not TCM was effective in tackling particularly challenging behaviour was more mixed.

CONCLUSIONS

Our findings suggest that teachers experience the TCM programme as beneficial. This is discussed alongside other qualitative and quantitative studies in this field.

The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial

BACKGROUND

We evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools' important influence on child mental health.

METHODS

A two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes.

TRIAL REGISTRATION

ISRCTN84130388.

RESULTS

Eighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = -1.0; 95% CI-1.9 to -0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health.

CONCLUSIONS

TCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.

Training teachers in classroom management to improve mental health in primary school children: the STARS cluster RCT

Background

Poor mental health in childhood is common, persistent and associated with a range of adverse outcomes that include persistent psychopathology, as well as risk-taking behaviour, criminality and educational failure, all of which may also compromise health. There is a growing policy focus on children’s mental health and the role of schools in particular in addressing this.

Objectives

To evaluate whether or not the Incredible Years®(IY) Teacher Classroom Management (TCM) training improved children’s mental health, behaviour, educational attainment and enjoyment of school, improved teachers’ mental health and relationship with work, and was cost-effective in relation to potential improvements.

Design

A two-arm, pragmatic, parallel-group, superiority, cluster randomised controlled trial.

Setting

A total of 80 UK schools (clusters) were recruited in three distinct cohorts between 2012 and 2014 and randomised to TCM (intervention) or teaching as usual [(TAU) control] with follow-ups at 9, 18 and 30 months. Schools and teachers were not masked to allocation.

Participants

Eighty schools (n = 2075 children) were randomised: 40 (n = 1037 children) to TCM and 40 (n = 1038 children) to TAU.

Interventions

TCM was delivered to teachers in six whole-day sessions, spread over 6 months. The explicit goals of TCM are to enhance classroom management skills and improve teacher–student relationships.

Main outcome measures

The primary planned outcome was the teacher-reported Strengths and Difficulties Questionnaire Total Difficulties (SDQ-TD) score. Random-effects linear regression and marginal logistic regression models using generalized estimating equations were used to analyse outcomes.

Results

The intervention reduced the SDQ-TD score at 9 months [adjusted mean difference (AMD) –1.0, 95% confidence interval (CI) –1.9 to –0.1;p = 0.03] but there was little evidence of effects at 18 months (AMD –0.1, 95% CI –1.5 to 1.2;p = 0.85) and 30 months (AMD –0.7, 95% CI –1.9 to 0.4;p = 0.23). Planned subgroup analyses suggested that TCM is more effective than TAU for children with poor mental health. Cost-effectiveness analysis using the SDQ-TD suggested that the probability of TCM being cost-effective compared with TAU was associated with some uncertainty (range of 40% to 80% depending on the willingness to pay for a unit improvement in SDQ-TD score). In terms of quality-adjusted life-years (QALYs), there was evidence to suggest that TCM was cost-effective compared with TAU at the National Institute for Health and Care Excellence thresholds of £20,000–30,000 per QALY at 9- and 18-month follow-up, but not at 30-month follow-up. There was evidence of reduced disruptive behaviour (p = 0.04) and reductions in inattention and overactivity (p = 0.02) at the 30-month follow-up. Despite no main effect on educational attainment, subgroup analysis indicated that the intervention’s effect differed between those who did and those who did not have poor mental health for both literacy (interactionp = 0.04) and numeracy (interactionp = 0.03). Independent blind observations and qualitative feedback from teachers suggested that teachers’ behaviour in the classroom changed as a result of attending TCM training.

Limitations

Teachers were not masked to allocation and attrition was marked for parent-reported data.

Conclusions

Our findings provide tentative evidence that TCM may be an effective universal child mental health intervention in the short term, particularly for primary school children who are identified as struggling, and it may be a cost-effective intervention in the short term.

Future work

Further research should explore TCM as a whole-school approach by training all school staff and should evaluate the impact of TCM on academic progress in a more thorough and systematic manner.

Trial registration

Current Controlled Trials ISRCTN84130388.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 6. See the NIHR Journals Library website for further project information. Funding was also provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (NIHR CLAHRC South West Peninsula).

The use of metronidazole gel to control the smell of malodorous lesions

Sixty-eight patients with malodorous lesions were treated with a topical 0.8% metronidazole gel for periods varying from a few days to 15 months. The gel completely controlled the foul smell of 34 (50%) lesions; had a reasonable effect on 31 (46%) and no effect on three. One patient with an infected leg ulcer was reported to have a skin irritation after seven days treatment with the gel. No other possible adverse events were reported.

Bisdionin C-a rationally designed, submicromolar inhibitor of family 18 chitinases

Chitinases of the GH18 family play important roles in a variety of pathogenic organisms and have also been shown to be involved in human asthma progression, making these enzymes potential drug targets. While a number of potent GH18 chitinase inhibitors have been described, in general, these compounds suffer from limited synthetic accessibility or unfavorable medicinal-chemical properties, making them poor starting points for the development of chitinase-targeted drugs. Exploiting available structural data, we have rationally designed bisdionin C, a submicromolar inhibitor of GH18 enzymes, that possesses desirable druglike properties and tractable chemical synthesis. A crystallographic structure of a chitinase-bisdionin C complex shows the two aromatic systems of the ligand interacting with two conserved tryptophan residues exposed in the active site cleft of the enzyme, while at the same time forming extensive hydrogen-bonding interactions with the catalytic machinery. The observed mode of binding, together with inhibition data, suggests that bisdionin C presents an attractive starting point for the development of specific inhibitors of bacterial-type, but not plant-type, GH 18 chitinases.

Screening-based discovery and structural dissection of a novel family 18 chitinase inhibitor

Family 18 chitinases play key roles in the life cycles of a variety of organisms ranging from bacteria to man. Very recently it has been shown that one of the mammalian chitinases is highly overexpressed in the asthmatic lung and contributes to the pathogenic process through recruitment of inflammatory cells. Although several potent natural product chitinase inhibitors have been identified, their chemotherapeutic potential or their use as cell biological tools is limited due to their size, complex chemistry, and limited availability. We describe a virtual screening-based approach to identification of a novel, purine-based, chitinase inhibitor. This inhibitor acts in the low micromolar (Ki=2.8+/-0.2 microM) range in a competitive mode. Dissection of the binding mode by x-ray crystallography reveals that the compound, which consists of two linked caffeine moieties, binds in the active site through extensive and not previously observed stacking interactions with conserved, solvent exposed tryptophans. Such exposed aromatics are also present in the structures of many other carbohydrate processing enzymes. The compound exhibits favorable chemical properties and is likely to be useful as a general scaffold for development of pan-family 18 chitinase inhibitors.

Structural insights into the mechanism and inhibition of eukaryotic O-GlcNAc hydrolysis

O-linked N-acetylglucosamine (O-GlcNAc) modification of specific serines/threonines on intracellular proteins in higher eukaryotes has been shown to directly regulate important processes such as the cell cycle, insulin sensitivity and transcription. The structure, molecular mechanisms of catalysis, protein substrate recognition/specificity of the eukaryotic O-GlcNAc transferase and hydrolase are largely unknown. Here we describe the crystal structure, enzymology and in vitro activity on human substrates of Clostridium perfringens NagJ, a close homologue of human O-GlcNAcase (OGA), representing the first family 84 glycoside hydrolase structure. The structure reveals a deep active site pocket highly conserved with the human enzyme, compatible with binding of O-GlcNAcylated peptides. Together with mutagenesis data, the structure supports a variant of the substrate-assisted catalytic mechanism, involving two aspartic acids and an unusually positioned tyrosine. Insights into recognition of substrate come from a complex with the transition state mimic O-(2-acetamido-2-deoxy-D-glucopyranosylidene)amino-N-phenylcarbamate (Ki=5.4 nM). Strikingly, the enzyme is inhibited by the pseudosubstrate peptide Ala-Cys(-S-GlcNAc)-Ala, and has OGA activity against O-GlcNAcylated human proteins, suggesting that the enzyme is a suitable model for further studies into the function of human OGA.

Internet addiction: a new type of addiction?

The popular press has discussed Internet addiction as an emerging disorder affecting thousands of people. However, little research has been done in this area. With the media reporting growing numbers of divorce, child neglect and loss of jobs associated with compulsive use of the Internet, professionals and lay persons alike are asking, "Does Internet addiction exist?" The authors review what has been studied to date and make suggestions as to how future research could be beneficial.