Title: Universal school-based prevention: examining the impact of the Good Behaviour Game on health-related outcomes for children
Funder: Department of Health and Social Care

Abstract: Mental health problems in children are a major education and public health priority (e.g. Davies, 2013; Department for Education, 2014). Universal school-based interventions can be a highly effective preventive strategy, but the evidence base in the UK is currently limited. The Good Behaviour Game (GBG) is an "interdependent group-oriented contingency management procedure" (Tingstrom et al, 2006, p.225) in which groups of children are rewarded for following four classroom rules: (1) We will work quietly, (2) We will be polite to others, (3) We will get out of seats with permission, and (4) We will follow directions. Over the school year, there is a natural evolution in the types of rewards used (from tangible rewards such as stickers to more abstract rewards such as free time), how long the game is played for (from 10 minutes to a whole lesson), at what frequency (from three times a week to every day), and when rewards are given (at the end of the game, end of the day, and at end of the week) (Elswick & Casey, 2011; Tingstrom et al., 2006). The GBG has a robust international evidence base that highlights its effect on both educational and health-related outcomes (e.g., Kellam et al, 2011; Flower et al, 2014), particularly for boys at-risk of developing conduct disorders (Kellam et al, 1994). It has not been rigorously trialled here, although a small scale pilot has demonstrated its acceptability and feasibility in English schools (Chan et al, 2012). We have funding from the Education Endowment Foundation (EEF) to conduct a 2-year cluster-randomised trial of the GBG in English primary schools that focuses on educational outcomes (reading and behaviour). 77 schools have been randomly assigned to deliver the GBG or continue practice as usual with children aged 7-8 (N=3,085) starting in September 2015. Technical support and assistance for schools in the intervention arm is being provided by Mentor UK and funded by the EEF. We are augmenting this trial so as to (i) collect additional data on health-related outcomes, (ii) perform an economic evaluation, and (iii) assess longer-term outcomes. Our primary outcome is children's mental health. Secondary outcomes are health-related quality of life, sources of resilience, bullying, school attendance and exclusions. A 2-year follow-up period involving repeated assessment of these outcomes (in addition to the educational outcomes specified above) will allow for the identification of maintenance and/or sleeper effects. We will analyse the data generated using a range of statistical techniques (e.g. hierarchical linear and structural equation modelling) to address six core questions. First, what is the effect of the GBG (when compared to usual practice) on health-related outcomes for children? Second, are there differential sub-group effects of the GBG (when compared to usual practice) for boys at-risk of developing conduct disorder? Third, to what extent are universal and sub-group effects moderated by implementation variability? Fourth, are universal and sub-group effects of the GBG maintained at 12- and 24-month follow-up (or, in the event of null effects, is a sleeper effect evident at at 12- and 24-month follow-up?). Fifth, what is the nature and magnitude of longitudinal associations between educational and health outcomes for children? Finally, what are the costs associated with the GBG and to what extent do the benefits generated represent value for money?

Lay abstract: Emotional and behavioural problems in children are a major concern - they interfere with their progress in school and in many cases, the negative effects can still be seen in adulthood. 'Universal' school-based interventions - in which every child in a given class takes part - may be a very effective way of preventing such problems before they take root. However, there is very little high quality research on such approaches in the UK. The Good Behaviour Game (GBG) is a universal intervention developed in the USA. Children in a given class are divided into teams. Each team is then rewarded for following four basic rules of behaviour: (1) We will work quietly, (2) We will be polite to others, (3) We will get out of seats with permission, and (4) We will follow directions. The game is won by any team with fewer than four infractions to these rules. Initially, the GBG is played 3 times a week for a short period of time (e.g. 10 minutes). The rewards are very concrete (e.g. stickers) and given immediately. Over time, the game evolves so that it is played for longer periods (e.g. a whole lesson), more frequently (e.g. every day), and for more abstract rewards (e.g. free time) that are given at the end of the day or week. The international evidence base for the GBG is very strong, but we do not know if it will be effective in the UK (although a pilot in Oxfordshire indicated that schools like it and could implement it). Our team already has funding from the Education Endowment Foundation (EEF) to run a major trial of the GBG in England that focuses on its effects on educational outcomes (e.g. reading, behaviour). 77 schools have been randomly assigned to deliver the GBG or carry on as usual with children in Year 3 (aged 7-8, of whom there are just over 3,000) starting in September 2015. The schools delivering the GBG have been trained and supported by coaches from Mentor UK. All of this is being funded by the EEF. The NIHR funding means that we can 'bolt on' to the EEF trial to (i) collect additional data on the impact of the GBG on children's health-related outcomes (e.g. mental health), (ii) determine if the GBG provides 'value for money', and (iii) find out if any effects of the GBG are maintained in the longer term (e.g. 12 and 24 months after the intervention is completed). The main outcome we are interested in is children's mental health. However, we will also collect data on quality of life, sources of resilience, bullying, school attendance and exclusions, because evidence from studies in other countries and/or the theory underpinning the GBG suggest that we may also see meaningful change in these areas. We will analyse the data collected using a variety of statistical tests. Where appropriate, we will draw upon data collected in the EEF educational trial. Our analyses will help us to answer six key questions: (1) What is the impact of the GBG on children's health-related outcomes? (2) Is the impact of the GBG greater for boys who are considered to be 'at risk' of developing behaviour problems? (3) Are the effects of the GBG influenced by how well it is implemented? (4) Are the effects of the GBG maintained over time? (5) Are children's educational and health-related outcomes related to each other over time? (6) Does the GBG represent good value for money?

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH