Recent evidence and young people’s perspectives #ActiveIngredientsMH
By Dr Monika Raniti and Divyangana Rakesh
Rates of depression and anxiety in young people have been increasing in recent years (Racine et al., 2021). While access to treatments is important, prevention is essential to reducing the burden of these problems worldwide. Schools are an important setting for supporting the mental health of young people. A common approach is to deliver individually-focussed mental health interventions (Nawaz & Cross, 2021) through the school curriculum (e.g., learning cognitive or behavioural skills), especially in high-income countries. Although these interventions can alleviate symptoms in individuals already experiencing difficulties, they are not particularly effective at preventing the onset of anxiety and depressive disorders and can be resource intensive and difficult to sustain (Caldwell et al., 2019). New approaches to prevention are urgently needed.
Schools are social environments that focus on learning and can influence mental health. For example, being bullied at school or disengaging from learning have been linked to poor mental health in young people (Moore et al., 2017; Wang & Fredricks, 2014). As part of our work on whole-school approaches to health and wellbeing (Sawyer, Raniti & Aston, 2021), our research team recently turned our attention to “school connectedness” as a potentially modifiable protective factor for depression and anxiety in young people.
School connectedness includes students’ thoughts (e.g., perceptions of relationships with teachers and peers), feelings (e.g., around sense of belonging), and behaviours (e.g., participation in school activities) towards the school environment, relationships within the school, and learning experiences, although definitions and measurement tools vary substantially (García-Moya et al., 2019; Hodges et al., 2018).
School connectedness has been associated with greater academic achievement and psychological wellbeing (Wang & Degol, 2016). Systematic reviews have shown links with less anxiety, depression and suicidal thoughts and behaviours (Aldridge et al., 2018; Marraccini & Brier, 2017). However, within these systematic reviews most studies were cross-sectional, often did control for key variables that might influence relationships (e.g., existing mental disorders), and did not examine anxiety and depression separately, making it difficult to determine the extent to which poor school connectedness may predict the onset of anxiety or depression in young people. Prospective studies are needed to overcome these methodological limitations that prevent a more robust understanding of the possible role of school connectedness in preventing depression and anxiety.
In the last few years, a number of prospective studies have been published that address some of the limitations of cross-sectional studies. One example is a recent study by Klinck, Vannucci, and McCauley Ohannessian (2020) who examined prospective relationships between school connectedness, and anxiety and depressive symptoms in adolescents aged 11 to 14 years. The primary aims of the study were to:
- Evaluate bidirectional relationships between school connectedness and anxiety and depressive symptoms
- Determine whether these relationships were stronger for adolescents at risk for an anxiety disorder or major depressive disorder (i.e., moderation).
Participants were seventh and eighth graders recruited from five public middle schools in Connecticut and central Massachusetts, New England, USA (two rural, one suburban, and two urban), where nearly half (48%) of all enrolled students were considered “economically disadvantaged”. Students (n = 1,589) were invited to participate in the study via mail and a parent opt-out consent process (2% opted-out). Consenting participants completed self-report surveys measuring school connectedness and anxiety and depressive symptoms at baseline and at 6-month follow-up. Cross-lagged path models using structural equation modelling were estimated using Mplus 8.0 statistical analysis software.
Study participants (n = 1,344 at baseline, n = 1,161 at 6-month follow-up) had a mean age of 12.73 years old at baseline (range 11 to 14 years; 51% female) and were racially/ethnically diverse (52% White, 21% Hispanic or Latinx, 9% Black or African American, 3% Asian, 15% multiracial/ethnic, and 1% other).
- There were prospective, bidirectional relationships found between school connectedness and depressive symptoms. That is:
- higher school connectedness at baseline predicted lower levels of depressive symptoms 6 months later,
- and higher levels of depressive symptoms at baseline predicted lower levels of school connectedness 6 months later.
- However, participants’ levels of anxiety at baseline affected these relationships. That is:
- the relationships between school connectedness and depression were only evident in students at low risk of an anxiety disorder at baseline,
- and there was no relationship between school connectedness and depression in students at high risk of an anxiety disorder.
- There were no significant prospective associations between school connectedness and anxiety symptoms, regardless of baseline risk for depression.
- This study shows that school connectedness and depression are related to each other over time, which builds on previous studies showing cross-sectional relationships.
- This provides evidence that feeling connected to school may be a protective factor against depressive symptoms and, if supported by other longitudinal and interventions studies, may be a good target for prevention.
- However, the relationship between school connectedness and depression was only identified in young people with low levels of anxiety and the study found no prospective relationships between school connectedness and anxiety.
- Although depression and anxiety often co-occur, these findings indicate the importance of examining depression and anxiety separately in future studies.
- They also suggest that pre-existing levels of depression and anxiety symptoms affect whether school connectedness predicts future mental health problems.
- Previous cross-sectional studies have found a relationship between school connectedness and anxiety levels, so it may be that this relationship is no longer significant when analysed with more robust statistical methods.
- Another possibility is school connectedness is more strongly linked to depression than anxiety.
Strengths and limitations
Strengths of this study include:
- A well-defined research question
- The prospective design
- Associations that were examined at different levels of baseline depression and anxiety
- The utilisation of reliable exposure and outcome variables; and
- A robust approach to including covariates (e.g., baseline age, gender, race/ethnicity, and perceived socioeconomic status) and addressing missing data.
There are also some limitations:
- Sample size was not justified which means we cannot be sure whether there were enough participants to detect an effect for the relationship between school connectedness and anxiety, if one truly exists within the population.
- P values were provided which indicate the statistical significance of an association, but estimates of effect size were not so we are unable to know the strength of the association between school connectedness and depression.
- The study examined anxiety and depressive symptoms only, not diagnosis. Therefore, 6 month follow up might be sufficient to detect symptom change but not necessarily disorder onset, especially given the age of participants at baseline (average age of onset is usually a little older than 12.5 years).
Implications for practice
- School social environments matter for mental health
- Schools that aim to improve school connectedness among their students are likely to improve the mental health of some students
- With additional evidence, school connectedness may be a potentially modifiable target for the prevention of depression
- Evidence for prospective relationships between school connectedness and later depression and anxiety should be synthesised to determine the extent and strength of these effects.
Our Active Ingredients review – school connectedness as a way to prevent anxiety or depression in young people
As this study by Klinck et al (2020) suggests, there are complex relationships between school connectedness, depression and anxiety over time. However, the extent to which school connectedness may prevent the onset of depression or anxiety or promote their remission is unclear.
Our team recently conducted a systematic review of the evidence for 1) prospective relationships between school connectedness and depression and anxiety, and 2) the effect of interventions to improve school connectedness on depression and anxiety, in young people aged 14 to 24 years old. You can check out a video summarising the review findings below.
As part of this work, we partnered with five youth advisors with lived experience of mental health problems and/or the schooling system (aged 16 to 21 years; located in Australia, Indonesia and The Philippines) to help us better understand the concept of school connectedness and its relationship with mental health. The main role of the advisers was to ensure that youth perspectives informed the interpretation and dissemination of the findings and future directions for research and practice.
Here we share some themes that arose from discussion with youth advisers:
1. School connectedness has multiple components
Youth advisers agreed with previous research definitions that school connectedness has many facets, and that the relationships you have with people at school are particularly important. Our youth advisers emphasised that school connectedness includes notions of:
- feeling acknowledged by teachers, peers, parents and the wider school community;
- relationships characterised by empathy, care, active communication, respect, and genuineness;
- a cohesive and welcoming school environment;
- feeling included, a sense of belonging and not feeling alone;
- feeling able to express your identity and personal strengths; and
- engaging in learning and participating in enjoyable school activities.
2. School connectedness is associated with better mental health, but not always
Based on their experience, youth advisers agreed that school connectedness is usually associated with better mental health, but not always. For example, knowing your school is there for you and being included by friends can make a person more motivated to learn and get involved in school activities. However, youth advisers also acknowledged that sometimes this can lead to academic pressure or worrying about expectations from others, which is not good for mental health. These insights encouraged us as researchers to be open to the possibility of individual variation when examining the relationship between school connectedness and depression and anxiety, and also the need to consider potential mechanisms underlying the relationship (e.g., academic stress).
3. Student voices are important for improving school connectedness
Youth advisers suggested that improving the underlying values of a school to improve communication and engagement between all members of the school community and increase representation of student voices is critical to improving school connectedness. They indicated that this creates a supportive and positive learning environment which in turn promotes good mental health, and therefore should be an integral part of future interventions designed to improve school connectedness. For example, having respectful and trusting relationships between students and adults at school (both teaching and non-teaching staff like security guards and bus drivers) and creating opportunities for students to support each other such as having a buddy/peer-to-peer mentoring system or leading school assemblies can foster a sense of school connectedness and good mental health.
Overall, our youth advisers reaffirmed that understanding school connectedness is an important part of supporting students’ mental health. Their insights are invaluable for guiding future research on this topic, especially as schools work to support the mental health of their students in the wake of the COVID-19 pandemic and changing learning environments.
Statement of interests
This work was funded by the Wellcome Trust’s Active Ingredients for Youth Anxiety and Depression Commission 2021.
Dr Monika Raniti has received funding from the Wellcome Trust as part of their Active Ingredients for Youth Anxiety and Depression Commission 2021 and from WHO and UNESCO as part of their Health Promoting Schools initiative. She is supported by funding from the Australian National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Driving Global Investment in Adolescent Health (GNT 1171981) and The ALIVE National Centre for Mental Health Research Translation funded by the NHMRC Special Initiative in Mental Health Grant APP2002047.
Divyangana Rakesh is supported by a Melbourne Research Scholarship and the Nick Christopher Scholarship.
Professor Susan Sawyer and Professor George Patton are part of the team funded by the Wellcome Trust to conduct a systematic review on the role of school connectedness in the prevention of youth depression and anxiety as part of the Active Ingredients for Youth Anxiety and Depression Commission 2021.
We thank Professor Susan Sawyer for her feedback on this article.
Thank you to our youth advisory committee in Australia, Indonesia and The Philippines: Jackson Smith, Clara Tambunan, Mary Patricia Lou Vinluan, Nuha Yahya, and Mac Zamani.