Transforming Adolescent Mental Health Through Accessible, Scalable, Technology-supported Small-group Instruction

Study Overview
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Brief Summary
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Adolescence is a developmental period of significant risk for anxiety, depressive symptoms, and suicidality, and the investigators propose to target key peer-based risk and protective factors using Cooperative Learning (CL). CL is a small-group instructional approach that can enhance peer relations and reduce peer-related risks, as well as promote academic engagement and achievement and reduce racial disparities. CL will be delivered with the aid of technology that automates the design and delivery of CL lessons, promoting rapid implementation, scalability, high fidelity, accessibility, and sustainability.

Detailed Description
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Internalizing symptoms (i.e., anxiety, depressive symptoms, suicidality) are alarmingly common among adolescents. In 2019, nearly 37% of high school students reported feeling anxious, sad, or hopeless, representing an increase from 2017 (i.e., 31%), and nearly 19% seriously considered suicide1, an increase from 2017 (17%). The coronavirus pandemic has exacerbated this problem, with research finding that social isolation resulting from the pandemic was linked to higher levels of stress, fear, loneliness, anxiety, depression, and suicide ideation among adolescents2-3. Importantly, ethnic/racial disparities have been documented in internalizing symptoms, with more negative outcomes for Latinas and Black males39-45. Current universal school-based approaches to prevention have reported uneven or limited effects, or no effects at all6-12. Questions have also been raised regarding cost and accessibility49-59. Despite the uneven track record of universal school-based (Tier 1) approaches, which has led some to recommend an emphasis on targeted (Tier 2) approaches48, Tier 1 programs possess several advantages. First, given the demographic heterogeneity in risk factors, as well as disparate access to high-quality, culturally-sensitive health care23, schools remain attractive as Tier 1 programs can ensure equitable access to primary prevention services. Second, universal programs avoid the difficulty of identifying adolescents at risk12, and third, Tier 1 programs minimize the risk of stigmatizing adolescents who seek out or are referred to services20-22. In this project, submitted to the Transformative Research Award initiative, the investigators will use cooperative learning (CL) as a universal (Tier 1) school-based prevention program to target malleable peer-based risk factors and subsequently evaluate how change in these mechanisms can reduce adolescent internalizing symptoms. CL targets various forms of maladaptive peer relations that create stress and comprise a significant risk factor for internalizing symptoms in adolescence; CL also promotes peer protective factors that can reduce the likelihood of internalizing symptoms (e.g., peer acceptance)27-34. CL has also been found to promote more cross-race interaction and interracial attraction, greater cross-ethnic academic support, and more frequent cross-ethnic friendships95-97. To support teachers in implementing CL, the investigators will use a Web-based software platform that provides an accessible, high-fidelity mechanism to deliver CL lessons. The investigators will not only test for intervention effects, but will also evaluate the relative strength of specific, theoretically-derived change mechanisms, and uncover key issues/barriers related to implementation that will allow the investigators to dynamically adjust our implementation approach to achieve maximum impact during subsequent scale-up. This project is designed to establish feasibility with teachers and schools and counter potential threats to implementation fidelity while also creating a roadmap to enhanced scalability and sustained implementation. Significant results from this project could inspire broad uptake of this approach in educational contexts, potentially addressing a significant public health need during a time of crisis due to the coronavirus pandemic.

Official Title
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Transforming Adolescent Mental Health Through Accessible, Scalable, Technology-supported Small-group Instruction

Conditions
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Anxiety Depression, Suicidal Ideation

Intervention / Treatment
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* Behavioral: PeerLearning.net


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All students and teachers in target grades in participating schools. Exclusion Criteria: None.

Ages Eligible for Study
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Minimum Age: 14 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: We will allocate 24 high schools to intervention wave using a stepped-wedge design. All 24 schools will begin in the control state at baseline (Fall 2022), and each fall one wave (N = 8 schools) will cross over until all schools have received the intervention. Students will be in 9th grade in the first year, and we will follow them into 10th, 11th, and then 12th grade, so in total we will be working in each school for four years.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Implementation of PeerLearning.net<br>Teachers in implementation schools will be given access to training and resources to implement PeerLearning.net as a core component of instruction. We will not create specific requirements of teachers but will ask that they deliver lessons with PeerLearning.net at least four times per month. We will monitor all teacher usage and thus will be able to promote greater usage by (1) publicly acknowledging teachers that are using it frequently and experiencing success, and (2) targeting teachers who use it infrequently with additional resources and support to encourage more frequent use. | Behavioral: PeerLearning.net<br>* PeerLearning.net provides an easy-to-use, scalable, and widely accessible means to support teachers in effectively designing and delivering high-fidelity Cooperative Learning (CL) lessons and, in turn, it has the potential to amplify the positive effects of CL found in previous research. Using PeerLearning.net, teachers design their lesson by selecting from among a set of typical CL lesson templates (e.g., jigsaw, peer tutoring, group projects) which they can customize and populate with their own curriculum and materials. These design templates represent the optimal, high-fidelity design that is required in order for CL to be successful. During lesson delivery, PeerLearning.net manages membership in learning groups, distributes instructional materials, directs student activities according to a pre-specified timetable, supports teacher observations of student behavior, and delivers post-lesson group activities and reviews.<br>|
| No Intervention: Pre-Intervention<br>Teachers in pre-intervention schools will continue with business as usual (i.e., typical instruction). Based upon previous experience in conducting research in school settings, we anticipate that teachers in pre-intervention schools will use CL very infrequently, and without the benefit of technology support. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Fall of Year 1 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Spring of Year 1 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Fall of Year 2 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Spring of Year 2 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Fall of Year 3 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Spring of Year 3 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Fall of Year 4 | 
| Generalized Anxiety Disorder 7 | Anxiety (scores zero to 3, higher scores imply worse outcome) | Spring of Year 4 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Fall of Year 1 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Spring of Year 1 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Fall of Year 2 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Spring of Year 2 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Fall of Year 3 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Spring of Year 3 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Fall of Year 4 | 
| Patient Health Questionnaire | Depressive symptoms (scores zero to 3, higher scores imply worse outcome) | Spring of Year 4 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Fall of Year 1 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Spring of Year 1 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Fall of Year 2 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Spring of Year 2 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Fall of Year 3 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Spring of Year 3 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Fall of Year 4 | 
| Youth Risk and Behavior Survey | Suicide ideation (scores zero to 6, higher scores imply worse outcome) | Spring of Year 4 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Fall of Year 1 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Spring of Year 1 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Fall of Year 2 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Spring of Year 2 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Fall of Year 3 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Spring of Year 3 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Fall of Year 4 | 
| Service Assessment for Children and Adolescents | Service utilization (scores zero to 20, higher scores imply worse outcome) | Spring of Year 4 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Fall of Year 1 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Spring of Year 1 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Fall of Year 2 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Spring of Year 2 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Fall of Year 3 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Spring of Year 3 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Fall of Year 4 | 
| Everyday Discrimination Scale | Discrimination (scores zero to 4, higher scores imply worse outcome) | Spring of Year 4 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 1 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 1 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 2 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 2 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 3 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 3 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 4 | 
| University of Illinois Bully Scale | Bullying and victimization (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 4 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Fall of Year 1 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Spring of Year 1 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Fall of Year 2 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Spring of Year 2 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Fall of Year 3 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Spring of Year 3 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Fall of Year 4 | 
| Child Peer Social Skills Scale | Peer acceptance (scores 1 to 5, higher scores imply better outcome) | Spring of Year 4 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Fall of Year 1 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Spring of Year 1 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Fall of Year 2 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Spring of Year 2 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Fall of Year 3 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Spring of Year 3 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Fall of Year 4 | 
| Perceived Stress Scale | Stress (scores 0 to 4, higher scores imply worse outcome) | Spring of Year 4 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 1 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 1 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 2 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 2 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 3 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 3 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Fall of Year 4 | 
| Adolescent Stress Questionnaire | Social stress (scores 1 to 5, higher scores imply worse outcome) | Spring of Year 4 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Fall of Year 1 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Spring of Year 1 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Fall of Year 2 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Spring of Year 2 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Fall of Year 3 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Spring of Year 3 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Fall of Year 4 | 
| Classroom Life Scale | Peer academic support (scores 1 to 5, higher scores imply better outcome) | Spring of Year 4 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Fall of Year 1 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Spring of Year 1 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Fall of Year 2 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Spring of Year 2 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Fall of Year 3 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Spring of Year 3 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Fall of Year 4 | 
| School Attendance | Degree of truancy (scores 0 to 4, lower scores imply better outcome) | Spring of Year 4 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Fall of Year 1 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Spring of Year 1 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Fall of Year 2 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Spring of Year 2 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Fall of Year 3 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Spring of Year 3 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Fall of Year 4 | 
| Reasons for Non-Attendance | Social issues causing non-attendance (scores 0 to 4, lower scores imply better outcome) | Spring of Year 4 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Fall of Year 1 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Spring of Year 1 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Fall of Year 2 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Spring of Year 2 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Fall of Year 3 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Spring of Year 3 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Fall of Year 4 | 
| UCLA Loneliness Scale | Loneliness (scores 1 to 3, lower scores imply better outcome) | Spring of Year 4 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Fall of Year 1 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Spring of Year 1 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Fall of Year 2 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Spring of Year 2 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Fall of Year 3 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Spring of Year 3 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Fall of Year 4 | 
| Secondary School Readiness Inventory | School engagement (scores 1 to 5, higher scores imply better outcome) | Spring of Year 4 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Fall of Year 1 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Spring of Year 1 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Fall of Year 2 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Spring of Year 2 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Fall of Year 3 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Spring of Year 3 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Fall of Year 4 | 
| Substance use | Use of tobacco, alcohol, and marijuana (scores 1 to 5, lower scores imply better outcome) | Spring of Year 4 |