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Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (Mage = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents’ antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

To understand the current state of research, a systematic review and meta-analysis were conducted to synthesize the effects of suicide prevention gatekeeper training (GKT) on participant behavioral intention to intervene and participant suicide intervention behaviors. Included studies examined GKT with adult participants and measured either behavioral intention to conduct a suicide intervention or the utilization of suicide intervention skills. Searches yielded a total of 43 studies from 46 reports, comprising 21,720 participants. To quantify change over time, the standardized mean gain effect size metric was utilized. Large effect sizes were found for behavioral intention from pre-training to post-training (1.03, 95% CI [0.80, 1.25]) and short-term follow-up (0.78, 95% CI [0.59, 0.97]). Smaller effect sizes were found for intervention behavior from pre-training to short-term (0.33, 95% CI [0.21, 0.46]) and long-term follow-up (0.22, 95% CI [0.14, 0.30]). Although this meta-analysis reveals a positive effect for GKT on behavioral outcomes, the low methodological quality of the currently available evidence limits the ability to draw conclusions from the synthesis. This work informs policymakers and interventionists on best practices for GKT and highlights that additional, rigorous research is needed.

This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non‐recovery schools. The review summarizes evidence from one quasi‐experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding. Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders. This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses. This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools. Plain language summary There is insufficient evidence to know whether recovery high schools and collegiate recovery communities are effective Evidence that recovery high schools (RHSs) may improve academic and substance use outcomes is based on the findings from a single study with a serious risk of bias. The review in brief Very limited evidence addresses the effectiveness of recovery high schools (RHSs). There is no rigorous evidence on the effectiveness of collegiate recovery communities (CRCs). It is unclear whether CRCs are effective in promoting academic success and reducing substance use among college students. What is this review about? Based on the results of one study, RHSs may reduce high school students' school absenteeism, marijuana use, and other drug use, and increase abstinence from drugs; but RHSs may be no better or worse than other high schools in improving grades, reducing truancy, or reducing alcohol use. What is the aim of this review? This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non‐recovery schools. The review summarizes evidence from one quasi‐experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding. What are the main findings of this review? Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders. This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses. This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools. What studies are included? The included study of recovery high schools used a controlled quasi‐experimental pretest‐posttest design and reported on the following outcomes: grade point average, truancy, school absenteeism, alcohol use, marijuana use, other drug use, and abstinence from alcohol/drugs. The included study focused on a sample of U.S. high school students. There were no eligible studies of CRCs. What do the findings of this review mean? Findings from this review indicate insufficient evidence on the effects of recovery schools on student well‐being. Although there is some indication RHSs may improve academic and substance use outcomes, this is based on the findings from a single study. There is no available evidence on the effects of CRCs. No strong conclusions can be drawn at this time, given the lack of available evidence on RHSs and CRCs, and the serious risk of bias in the one RHS study included in the review. The evidence from this review suggests there is a clear need for additional rigorous evaluations of recovery school effects prior to widespread implementation. How up‐to‐date is this review? The review authors searched for studies until September 2018. This Campbell systematic review was published in 2018. Executive Summary/Abstract BACKGROUND Substance use disorders (SUDs) among youth are a major public health problem. In the United States, for example, the incidence of SUDs increases steadily after age 12 and peaks among youth ages 18–23 (White, Evans, Ali, Achara‐Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with an SUD, approximately 7–9% of 12–24 year olds in the United States were admitted for public SUD treatment in 2013 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Recovery from an SUD involves reduction or complete abstinence of use, defined broadly as “voluntarily sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society” (UK Drug Policy Commission, 2008). However, SUDs are often experienced as chronic conditions; among youth who successfully complete substance use treatment, approximately 45–70% return to substance use within months of treatment discharge (Anderson, Ramo, Schulte, Cummins, & Brown, 2007; Brown, D'Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown et al., 2001; Ramo et al., 2012; White et al., 2004). Success and engagement at school and in postsecondary education are critical to healthy youth development. For youth in recovery from SUDs, school attendance, engagement, and achievement build human capital by motivating personal growth, creating new opportunities and social networks, and increasing life satisfaction and meaning (Keane, 2011; Terrion, 2012; 2014). Upon discharge from formal substance use treatment settings, schools become one of the most important social environments in the lives of youth with SUDs. Healthy school peer environments can enable youth to replace substance use behaviors and norms with healthy activities and prosocial, sober peers. Conversely, many school environments may be risky for youth in recovery from SUDs due to perceived substance use among peers, availability of drugs or alcohol, and substance‐approving norms on campus (Centers for Disease Control [CDC], 2011; Spear & Skala, 1995; Wambeam, Canen, Linkenbach, & Otto, 2014). Given the many social and environmental challenges faced by youth in recovery from substance use, recovery‐specific institutional supports are increasingly being linked to educational settings. The two primary types of education‐based continuing care supports for youth in recovery, defined under the umbrella term of “recovery schools” for this review, are recovery high schools (RHSs) and collegiate recovery communities (CRCs). RHSs are secondary schools that provide standard high school education and award secondary school diplomas, but also include therapeutic programming aimed at promoting recovery (e.g., group check‐ins, community service, counseling sessions). CRCs also provide recovery oriented support services (e.g., self‐help groups, counseling sessions, sober dorms) for students, but are embedded within larger college or university settings. The primary aims of RHSs and CRCs are to promote abstinence and prevent relapse among students, and thus ultimately improve students' academic success. OBJECTIVES This review summarized and synthesized the available research evidence on the effects of recovery schools for improving academic success and behavioural outcomes among high school and college students who are in recovery from substance use. The specific research questions that guided the review are as follows: 1. What effect does recovery school attendance (versus attending a non‐recovery or traditional school setting) have on academic outcomes for students in recovery from substance use? Specifically (by program type): a. For recovery high schools: what are the effects on measures of academic achievement, high school completion, and college enrolment? b. For collegiate recovery communities: what are the effects on measures of academic achievement and college completion? 2. What effect does recovery school attendance have on substance use outcomes for students in recovery from substance use? Specifically, what are the effects on alcohol, marijuana, cocaine, or other substance use? 3. Do the effects of recovery schools on students' outcomes vary according to the race/ethnicity, gender, or socioeconomic status of the students? 4. Do the effects of recovery schools on students' outcomes vary according to existing mental health comorbidity status or juvenile justice involvement of the students? SEARCH METHODS We aimed to identify all published and unpublished literature on recovery schools by using a comprehensive and systematic literature search. We searched multiple electronic databases, research registers, grey literature sources, and reference lists from prior reviews; and contacted experts in the field. SELECTION CRITERIA Studies were included in the review if they met the following criteria: Types of studies: Randomized controlled trial (RCT), quasi‐randomized controlled trial (QRCT), or controlled quasi‐experimental design (QED). Types of participants: Students in recovery from substance use who were enrolled part‐time or full‐time in secondary (high school) or postsecondary (college or university) educational institutions. Types of interventions: Recovery schools broadly defined as educational institutions, or programs at educational institutions, developed specifically for students in recovery and that address recovery needs in addition to academic development. Types of comparisons: Traditional educational programs or services that did not explicitly have a substance use recovery focus. Types of outcome measures: The review focused on primary outcomes in the following two domains: academic performance (e.g., achievement test scores, grade‐point average, high school completion, school attendance, college enrolment, college completion) and substance use (alcohol, marijuana, cocaine, heroin, stimulant, mixed drug use, or other illicit drug use). Studies that met all other eligibility criteria were considered eligible for the narrative review portion of this review even if they did not report outcomes in one of the primary outcome domains. Other criteria: Studies must have been reported between 1978 and 2016. The search was not restricted by geography, language, publication status, or any other study characteristic. DATA COLLECTION AND ANALYSIS Two reviewers independently screened all titles and abstracts of records identified in the systematic search. Records that were clearly ineligible or irrelevant were excluded at the title/abstract phase; all other records were retrieved in full‐text and screened for eligibility by two independent reviewers. Any discrepancies in eligibility assessments were discussed and resolved via consensus. Studies that met the inclusion criteria were coded by two independent reviewers using a structured data extraction form; any disagreements in coding were resolved via discussion and consensus. If members of the review team had conducted any of the primary studies eligible for the review, external and independent data collectors extracted data from those studies. Risk of bias was assessed using the ROBINS‐I tool for non‐randomized study designs (Sterne, Higgins, & Reeves, 2016). Inverse variance weighted random effects meta‐analyses were planned to synthesize effect sizes across studies, as well as heterogeneity analysis, subgroup analysis, sensitivity analysis, and publication bias analysis. However, these synthesis methods were not used given that only one study met the inclusion criteria for the review. Instead, effect sizes (and their corresponding 95% confidence intervals) were reported for all eligible outcomes reported in the study. RESULTS Only one study met criteria for inclusion in the review. This study used a QED to examine the effects of RHSs on high school students' academic and substance use outcomes. No eligible studies examining CRCs were identified in the search. The results from the one eligible RHS study indicated that after adjusting for pretest values, students in the RHS condition reported levels of grade point averages (= 0.26, 95% CI [‐0.04, 0.56]), truancy (= 0.01, 95% CI [‐0.29, 0.31]), and alcohol use (= 0.23, 95% CI [‐0.07, 0.53]) similar to participants in the comparison condition. However, students in the RHS condition reported improvements in absenteeism (= 0.56, 95% CI [0.25, 0.87]), abstinence from alcohol/drugs (OR = 4.36, 95% CI [1.19, 15.98]), marijuana use (= 0.51, 95% CI [0.20, 0.82]), and other drug use (= 0.45, 95% CI [0.14, 0.76]). Overall, there was a serious risk of bias in the one included study. The study had a serious risk of bias due to confounding, low risk of bias due to selection of participants into the study, moderate risk of bias due to classification of interventions, inconclusive risk of bias due to deviations from intended interventions, inconclusive risk of bias due to missing data, moderate risk of bias in measurement of outcomes, and low risk of bias in selection of reported results. AUTHORS’ CONCLUSIONS There is insufficient evidence regarding the effectiveness of RHSs and CRCs for improving academic and substance use outcomes among students in recovery from SUDs. Only one identified study examined the effectiveness of RHSs. Although the study reported some beneficial effects, the results must be interpreted with caution given the study's potential risk of bias due to confounding and limited external validity. No identified studies examined the effectiveness of CRCs across the outcomes of interest in this review, so it is unclear what effects these programs may have on students' academic and behavioral outcomes. The paucity of evidence on the effectiveness of recovery schools, as documented in this review, thus suggest the need for caution in the widespread adoption of recovery schools for students in recovery from SUDs. Given the lack of empirical support for these recovery schools, additional rigorous evaluation studies are needed to replicate the findings from the one study included in the review. Furthermore, additional research examining the costs of recovery schools may be needed, to help school administrators determine the potential cost‐benefits associated with recovery schools.

Executive summary Single‐case research designs are critically important for understanding the effectiveness of interventions that target individuals with low incidence disabilities (e.g., physical disabilities, autism spectrum disorders). These designs comprise an important part of the evidence base in fields such as special education and school psychology, and can provide credible and persuasive evidence for guiding practice and policy decisions. In this paper we discuss the development and use of between‐case standardized mean difference effect sizes for two popular single‐case research designs (the treatment reversal design and the multiple baseline design), and discuss how they might be used in meta‐analyses either with other single‐case research designs or in conjunction with between‐group research designs. Effect size computation is carried out using a user‐friendly web application, scdhlm, powered by the free statistical program R; no knowledge of R programming is needed to use this web application.

The objectives of this systematic review were to summarize the available evidence on the effects of prevention and intervention programs aimed at primary and secondary students for increasing school completion or reducing school dropout. The primary focus of the meta‐analysis was to examine the comparative effectiveness of different programs and program approaches in an effort to identify those with the largest and most reliable effects on school completion and dropout outcomes. We also sought to summarize the effects of programs designed for pregnant and parenting teens. A comprehensive and diverse international search strategy was used to locate qualifying studies reported between 1985 and 2010. The literature search yielded a total of 23,677 reports, 2,794 which were deemed potentially relevant and retrieved for eligibility determination. Of those, 548 reports describing 167 different studies were included in the final review. Overall, results indicated that most school‐ and community‐based programs were effective in decreasing school dropout. Given the minimal variation in effects across program types, the main conclusion from this review is that dropout prevention and intervention programs, regardless of type, will likely be effective if they are implemented well and are appropriate for the local environment. We recommend that policy makers and practitioners choosing dropout prevention programs consider the cost‐effectiveness of programs, and choose those that fit best with local needs as well as implementer abilities and resources. Executive Summary/Abstract BACKGROUND Dropping out of high school is associated with numerous detrimental consequences, including low wages, unemployment, incarceration, and poverty. There are a large number of school and community‐based prevention and intervention programs for general population and at‐risk students, and there are a number of programs designed specifically to encourage school completion among pregnant and parenting teens. No comprehensive systematic reviews have examined these programs' overall effectiveness. OBJECTIVES The objectives of this systematic review were to summarize the available evidence on the effects of prevention and intervention programs aimed at primary and secondary students for increasing school completion or reducing school dropout. The primary focus of the meta‐analysis was to examine the comparative effectiveness of different programs and program approaches in an effort to identify those with the largest and most reliable effects on school completion and dropout outcomes. We also sought to summarize the effects of programs designed for pregnant and parenting teens. SEARCH STRATEGY A comprehensive and diverse international search strategy was used to locate qualifying studies reported between 1985 and 2010. A wide range of electronic bibliographic databases were searched, along with research registers, other grey literature databases, reference lists of all previous meta‐analyses and reviews on the topic, as well as citations in research reports. We also maintained correspondence with researchers in the field of school dropout prevention. SELECTION CRITERIA Studies eligible for inclusion in the review were required to meet several eligibility criteria. First, studies must have involved a school‐based or affiliated psychological, educational, or behavioral prevention or intervention program intended to have beneficial effects on students recipients; or, evaluated a community‐based program explicitly presented as a dropout prevention or intervention program. Second, studies must have investigated outcomes for interventions directed toward school‐aged youth, or those expected to attend pre‐k to 12th grade primary and secondary schools or the equivalent. Third, studies must have used experimental or quasi‐experimental research designs, including random assignment, non‐random assignment with matching, or non‐random assignment with statistical controls or sufficient information to permit calculation of pre‐treatment effect size group equivalence. Fourth, studies must have reported at least one eligible outcome variable measuring school completion, school dropout, high school graduation, or school attendance. Finally, the date of publication or reporting of the study must have been in 1985 or later. DATA COLLECTION AND ANALYSIS The literature search yielded a total of 23,677 reports, 2,794 which were deemed potentially relevant and retrieved for eligibility determination. Of those, 548 reports describing 167 different studies were included in the final review. Random‐effects inverse variance weighted meta‐analytic methods were used to synthesize odds ratios for the school dropout outcomes. Meta‐regression models were used to examine the effects of program characteristics, methodological characteristics, and participant characteristics on the dropout odds ratios. Funnel plots, regression tests for small sample bias, and trim and fill analyses were used to assess the possibility of publication bias. RESULTS General dropout programs (152 studies; 317 independent samples) and dropout programs for teen parents (15 studies; 51 independent samples) were analyzed in separate meta‐analyses. Overall, both general dropout programs and programs specialized for teen parents were effective in reducing school dropout (or increasing school completion). The random effects weighted mean odds ratio for the general programs was 1.72. Using the average dropout rate for control groups of 21.1%, the odds ratio for the general programs translates to a dropout rate of 13%. For the teen parent programs, the mean odds ratio for graduation and dropout outcomes was 1.83 and was 1.55 for school enrollment outcomes. The average graduation rate for the young women in comparison groups was 26%. The corresponding graduation rate for young mothers in the intervention programs was 39%. For school enrollment outcomes, the average enrollment rate for the comparison mothers was 33%. The mean odds ratio of 1.55 for these studies translates into an enrollment rate of about 43%. Moderator analyses for the general programs indicated that studies with similar program and comparison groups at baseline and those that provided posttest data adjusted for baseline non‐equivalence produced smaller effect sizes. For teen parent programs, moderator analyses found that random and matched designs produced smaller effect sizes than non‐random or non‐matched designs. Effect sizes were therefore adjusted for methodological characteristics to examine the effects of different program types net of the influence of method. The effects were generally consistent across different types of programs and for different types of participant samples. However, higher levels of implementation quality tended to be associated with larger effects. Analyses provided no strong indication of the presence of publication or small study bias. AUTHOR'S CONCLUSIONS Overall, results indicated that most school‐ and community‐based programs were effective in decreasing school dropout. Given the minimal variation in effects across program types, the main conclusion from this review is that dropout prevention and intervention programs, regardless of type, will likely be effective if they are implemented well and are appropriate for the local environment. We recommend that policy makers and practitioners choosing dropout prevention programs consider the cost‐effectiveness of programs, and choose those that fit best with local needs as well as implementer abilities and resources.

The objectives of this Campbell systematic review were to respond to the following questions: Main Question: What are the effects of interventions implemented in developing countries on measures of students' enrollment, attendance, graduation, and progression? Supplemental Question: Within those studies that report the effects of an intervention on measures of students' enrollment, attendance, graduation or progression, what are the ancillary effects on learning outcomes as measured by students' test scores, grades, and other achievement measures? The sample includes 73 experiments and quasi‐experiments. Across all interventions, the average effect size was positive in direction for all outcomes, and was largest for enrollment (d=.18; 95% CI[.13‐.24]), attendance (d=.15, 95% CI [.10‐.20]), progression (d=.13, 95% CI [.08‐.18]), math (d=.16, 95% CI [.10‐.23]) and language (d=.18, 95% CI [.12‐.25]) outcomes. However, the results were not uniform across every study; given the large variation in programs, participants, settings and designs, there was no surprise that there was significant heterogeneity in effect sizes in these main analyses. Based on the evidence presented in this report, interventions that address getting children into school and keeping them there have, on average, positive effects. This is also true of learning outcomes reported within those same studies. Although effects could be considered small, they represent 3‐9% increases in positive outcomes compared to the control/comparison group in the studies. Policymakers would have to assess whether such outcomes are worth investments, given costs of implementation and how widespread the problem is that the intervention will address. Executive Summary BACKGROUND Education is considered critical to economic development and social welfare in developing nations. In light of compelling evidence that links expanded education systems and socioeconomic development while highlighting the importance of policies to offset inequality in access, governments and donor agencies have invested considerable funding to promote educational initiatives. Considerable funding for such initiatives has brought with it a concomitant increase in accountability and decision‐makers want to know if the funds they have put toward such programs are having positive impact. Concurrently, there has also been a rise in impact evaluations in the developing world, particularly in education. Given the importance of education, particularly to outcomes in the most economically challenged nations, the amount of interventions that have been implemented to address education in developing nations, and the increase in relevant controlled impact evaluations, the need for a systematic review seems clear. No systematic review of randomized controlled trials and quasi‐experiments of strategies in developing nations to get children into school (enrollment) and keep them there (attendance, persistence, continuation) has yet been reported, nor has any looked at supplemental outcomes focused on learning. By systematically gathering and analyzing rigorous research about the program effects of primary and secondary school enrollment and completion policies, our review will hopefully provide evidence to inform the next wave of funding, intervention and evaluation efforts in this area. OBJECTIVES For this project, our objectives were to respond to the following questions: • Main Question: What are the effects of interventions implemented in developing countries on measures of students' enrollment, attendance, graduation, and progression? • Supplemental Question: Within those studies that report the effects of an intervention on measures of students' enrollment, attendance, graduation or progression, what are the ancillary effects on learning outcomes as measured by students' test scores, grades, and other achievement measures? SEARCH STRATEGY Five main strategies were used to identify eligible reports: (1) electronic searches of bibliographic databases; (2) hand searches of relevant journals; (3) examining the citations of every retrieved report; (4) contacting the “informal college” of researchers working in the area; and (5) searches of the internet and specialized holdings. SELECTION CRITERIA To be eligible, studies had to: (1) assess the impact of an intervention that included primary or secondary school outcomes (Kindergarten‐12th grade in the U.S. context) relevant to the main research question; (2) use a randomized controlled trial (with or without baseline control), or a quasi‐experimental approach in which baseline controls on main outcomes were included; (3) be conducted in a country classified as a “low or middle income nation” by the World Bank at the time the intervention being studied was implemented; (4) include at least one quantifiable main outcome measure (enrollment, attendance, dropout, or progression); (5) be published or made available before December 2009, without regard to language or publication type; and (6) include data on participants from 1990 or beyond. If a study satisfied those criteria, we then examined it for quantifiable measures relevant to the supplemental question on learning outcomes. These studies are not representative, of course, of all evaluations that included learning outcomes, but only of those studies that included learning outcomes along with at least one quantifiable outcome of enrollment, attendance, dropout and progression. DATA COLLECTION AND ANALYSIS A preliminary instrument was designed to extract data on substantive and methodological characteristics from each of the reports. Standardized mean difference (Cohen's d) effect sizes were computed for the first effect reported in each study. Given the presumed heterogeneity of true effects in the population, analyses of effect sizes were estimated using random effects models. Main effects were analyzed for each main outcome reported: enrollment, attendance, dropout, and progression. Supplemental learning outcomes reported within the same studies were also coded; these included math, language, standardized assessment scores, and other achievement measures. Seven moderator analyses were also conducted. RESULTS The sample includes 73 experiments and quasi‐experiments. Across all interventions, the average effect size was positive in direction for all outcomes, and was largest for enrollment (d=.18; 95% CI[.13‐.24]), attendance (d=.15, 95% CI [.10‐.20]), progression (d=.13, 95% CI [.08‐.18]), math (d=.16, 95% CI [.10‐.23]) and language (d=.18, 95% CI [.12‐.25]) outcomes. However, the results were not uniform across every study; given the large variation in programs, participants, settings and designs, there was no surprise that there was significant heterogeneity in effect sizes in these main analyses. Examining only outcomes of enrollment and attendance (n=59), studies that focused on new schools and other infrastructure interventions (d=.44, 95% CI [.40‐.47]) reported the largest average effects. Studies that were conducted either in Europe or Central Asia (d=.58, 95% CI [.23‐.93]), or East Asia and the Pacific (d=.36, 95% CI [.25‐.48]), were also associated with larger average effects. AUTHORS' CONCLUSIONS Based on the evidence presented in this report, interventions that address getting children into school and keeping them there have, on average, positive effects. This is also true of learning outcomes reported within those same studies. Although effects could be considered small, they represent 3‐9% increases in positive outcomes compared to the control/comparison group in the studies. Policymakers would have to assess whether such outcomes are worth investments, given costs of implementation and how widespread the problem is that the intervention will address.

This Campbell systematic review examines the impact of later school start times on student academic performance, mental health and family and community outcomes. The review summarises findings from 17 reports of 11 interventions in six countries. Later school start times appear to increase sleeping time. And there is a positive association between later school start times and academic and psychosocial outcomes. The evidence on absenteeism and student alertness is mixed. However, the quality of the evidence and comparability of studies is low. Adverse effects may be reduced interaction with parents, and staffing and scheduling difficulties. There is insufficient evidence to draw firm conclusions concerning these possible adverse effects. Plain language summary Later school start times may produce benefits for students but more evidence is needed There is a positive association between later school start times and academic and psychosocial outcomes. The review in brief Later school start times may have beneficial effects for student mental health and academic performance. There appear to be some positive effects from later start times, but the evidence base is too weak to have confidence in the findings. Additional research is needed. What is this review about? Later school start times have been implemented around the world as a means of avoiding the potentially negative impacts that early morning schedules can have on adolescent students. Even mild sleep deprivation has been associated with significant health and educational concerns: increased risk for accidents and injuries, impaired learning, aggression, memory loss, poor self‐esteem, and changes in metabolism. This review examines the effects of later start times on these outcomes. What is the aim of this review? This Campbell systematic review examines the impact of later school start times on student academic performance, mental health and family and community outcomes. The review summarises findings from 17 reports of 11 interventions in six countries. What studies are included? Included studies were randomized controlled trials, controlled before‐and‐after studies, and interrupted time series studies with data for students aged 13 to 19 years and that compared different school start times. Studies had to report either primary outcomes of interest (academic outcomes, amount or quality of sleep, mental health indicators, attendance, or alertness) or secondary outcomes (health behaviors, health and safety indicators, social outcomes, family outcomes, school outcomes, or community outcomes) were eligible. The evidence base covers 17 studies reporting on 11 unique interventions with 297,994 participants. Six studies took place in the USA, and one study each was in Brazil, Canada, Croatia, Israel, and New Zealand. What are the main results in this review? Later school start times appear to increase sleeping time. And there is a positive association between later school start times and academic and psychosocial outcomes. The evidence on absenteeism and student alertness is mixed. However, the quality of the evidence and comparability of studies is low. Adverse effects may be reduced interaction with parents, and staffing and scheduling difficulties. There is insufficient evidence to draw firm conclusions concerning these possible adverse effects. What do the findings in this review mean? This systematic review on later school start times suggests several potential benefits for this intervention and points to the need for higher quality primary studies. However, because of the limited evidence base, we could not determine the effects of later school start times with any confidence. How up‐to‐date is this review? The review authors searched for studies published up to February 2016. This Campbell systematic review was published in December 2017. Executive summary/Abstract Background A number of school systems worldwide have proposed and implemented later school start times as a means of avoiding the potentially negative impacts that early morning schedules can have on adolescent students. Even mild sleep deprivation has been associated with significant health and educational concerns: increased risk for accidents and injuries, impaired learning, aggression, memory loss, poor self‐esteem, and changes in metabolism. Although researchers have begun to explore the effects of delayed school start time, no one has conducted a rigorous review of evidence to determine whether later school start times support adolescent health, education, and well‐being. Objectives We aimed to assess the effects of a later school start time for supporting health, education, and well‐being in high school students. Secondary objectives were to explore possible differential effects of later school start times in student subgroups and in different types of schools; to identify implementation practices, contextual factors, and delivery modes associated with positive and negative effects of later start times; and to assess the effects of later school start times on the broader community (high school faculty and staff, neighborhood, and families). Search methods We conducted the main search for this review on 28 October 2014 and updated it on 8 February 2016. We searched CENTRAL as well as 17 key electronic databases (including MEDLINE, Embase, ERIC, PsycINFO, and Sociological Abstracts), current editions of relevant journals and organizational websites, trial registries, and Google Scholar. Selection criteria We included any randomized controlled trials, controlled before‐and‐after studies, and interrupted time series studies with sufficient data points that pertained to students aged 13 to 19 years and that compared different school start times. Studies that reported either primary outcomes of interest (academic outcomes, amount or quality of sleep, mental health indicators, attendance, or alertness) or secondary outcomes (health behaviors, health and safety indicators, social outcomes, family outcomes, school outcomes, or community outcomes) were eligible. Data collection and analysis At least two review authors independently determined inclusion and exclusion decisions through screening titles, abstracts, and full‐text reports. Two review authors independently extracted data for all eligible studies. We presented findings through a narrative synthesis across all studies. When two or more study samples provided sufficient information to permit effect size calculations, we conducted random‐effects meta‐analyses to synthesize effects across studies. Results Our search located 17 eligible records reporting on 11 unique studies with 297,994 participants; the studies examined academic outcomes, amount and quality of sleep, mental health indicators, attendance, and student alertness. Overall, the quality of the body of evidence was very low, as we rated most studies as being at high or unclear risk of bias with respect to allocation, attrition, absence of randomization, and the collection of baseline data. Therefore, we cannot be confident about the effects of later school start times. Preliminary evidence from the included studies indicated a potential association between later school start times and academic and psychosocial outcomes, but quality and comparability of these data were low and often precluded quantitative synthesis. Four studies examined the association between later school start times and academic outcomes, reporting mixed results. Six studies examined effects on total amount of sleep and reported significant, positive relationships between later school start times and amount of sleep. One study provided information concerning mental health outcomes, reporting an association between decreased depressive symptoms and later school start times. There were mixed results for the association between later school start times and absenteeism. Three studies reported mixed results concerning the association between later school start times and student alertness. There was limited indication of potential adverse effects on logistics, as the qualitative portions of one study reported less interaction between parents and children, and another reported staffing and scheduling difficulties. Because of the insufficient evidence, we cannot draw firm conclusions concerning adverse effects at this time. It is important to note the limitations of this evidence, especially as randomized controlled trials and high‐quality primary studies are difficult to conduct; school systems are often unwilling or unable to allow researchers the necessary control over scheduling and data collection. Moreover, this evidence does not speak to the process of implementing later school starts, as the included studies focused on reporting the effects rather than exploring the process. Authors’ conclusions This systematic review on later school start times suggests several potential benefits for this intervention and points to the need for higher quality primary studies. However, as a result of the limited evidence base, we could not determine the effects of later school start times with any confidence.

Stress and stress‐related mental health problems are major causes of illness and disability. Mindfulness‐based stress reduction (‘MBSR’) is a group‐based health promotion intervention to improve health and the way people deal with stress and life?s challenges. The core ingredient is mindfulness training through physical and mental exercises practiced daily for eight weeks. The mindful non‐judgmental attitude of being present with what arises is practiced in the formal exercises and in everyday situations. This review assesses the effect of MBSR programs on outcome measures of mental and physical health, quality of life and social functioning in adults. MBSR has a moderately large effect on outcome measures of mental health, somatic health, and quality of life including social function at post‐intervention when compared to an inactive control. If 100 people go through the MBSR program, 21 more people will have a favourable mental health outcome compared to if they had been put on a wait‐list or gotten only the usual treatment. These results may be inflated by underreporting of negative trials and moderate heterogeneity (indicating differences between the trials). MBSR has a small but significant effect on improving mental health at post‐intervention compared to other active treatments. MBSR has the same effect as other active interventions on somatic health, and quality of life (including social function). There was no underreporting of negative trials, and heterogeneity (differences between trials) were small for mental health, moderate for quality of life and large for somatic health. The effects were similar across all target groups and were generally maintained at follow‐up (1?34 months). The effects were largely independent of gender and study sample. The effects seemed also largely independent of duration and compliance with the MBSR intervention. No studies report results regarding side‐effects or costs. Effects were strongly correlated to the effects on measures of mindfulness, indicating that the effects may be related to the increase in self‐reported mindfulness. Two thirds of the included studies showed a considerable risk of bias, which was higher among studies with inactive than active control groups. Studies of higher quality reported lower effects than studies with low quality. The overall quality of the evidence was moderate, indicating moderate confidence in the reported effect sizes. Further research may change the estimate of effect. Plain language summary Mindfulness training improves health and quality of life for adults Mindfulness‐based stress reduction (MBSR) is used to improve health, quality of life and social functioning. MBSR has a positive effect on mental health outcomes measured right after the intervention and at follow up. It also improves personal development, quality of life, and self‐reported mindfulness. What is this review about? Stress and stress‐related mental health problems are major causes of illness and disability. MBSR is a group‐based health promotion intervention to improve health and the way people deal with stress and life's challenges. The core ingredient is mindfulness training through physical and mental exercises practiced daily for eight weeks. The mindful non‐judgmental attitude of being present with what arises is practiced in the formal exercises and in everyday situations. This review assesses the effect of MBSR programs on outcome measures of mental and physical health, quality of life and social functioning in adults. What is the aim of this review? This review summarizes all studies that compare the effect of a MBSR program to a control group intervention, in which the participants had been randomly allocated to be in either the MBSR group or a control group. The review summarizes the results in two categories. First, where the effect of the MBSR program was compared to an inactive group (either a wait list group or one receiving ordinary care also received by the MBSR group). Second, where MBSR was compared with an alternative active group intervention. What studies are included? The review summarizes 101 randomized controlled trials with a total of 8,135 participants from USA, Europe, Asia and Australia. Twenty‐two trials included persons with mild or moderate psychological problems, 47 targeted people with various somatic conditions and 32 of the studies recruited people from the general population. Seventy‐two studies compared MBSR to an inactive control group, while 37 compared MBSR to an active control intervention. Seven studies compared MBSR to both. Ninety‐six studies contributed data to the meta‐analyses, with data from 7,647 participants. Is mindfulness effective? MBSR has a moderately large effect on outcome measures of mental health, somatic health, and quality of life including social function at post‐intervention when compared to an inactive control. If 100 people go through the MBSR program, 21 more people will have a favourable mental health outcome compared to if they had been put on a wait‐list or gotten only the usual treatment. These results may be inflated by underreporting of negative trials and moderate heterogeneity (indicating differences between the trials). MBSR has a small but significant effect on improving mental health at post‐intervention compared to other active treatments. MBSR has the same effect as other active interventions on somatic health, and quality of life (including social function). There was no underreporting of negative trials, and heterogeneity (differences between trials) were small for mental health, moderate for quality of life and large for somatic health. The effects were similar across all target groups and were generally maintained at follow‐up (1–34 months). The effects were largely independent of gender and study sample. The effects seemed also largely independent of duration and compliance with the MBSR intervention. No studies report results regarding side‐effects or costs. Effects were strongly correlated to the effects on measures of mindfulness, indicating that the effects may be related to the increase in self‐reported mindfulness. Two thirds of the included studies showed a considerable risk of bias, which was higher among studies with inactive than active control groups. Studies of higher quality reported lower effects than studies with low quality. The overall quality of the evidence was moderate, indicating moderate confidence in the reported effect sizes. Further research may change the estimate of effect. What do the findings of this review mean? Based on this review it is reasonable to consider MBSR a moderately well‐documented method for helping adults improve their health and cope better with the challenges and stress that life brings. New research should improve the way the trials are conducted addressing the pitfalls in research on mind‐body interventions. How up‐to‐date is this review? The review authors searched for studies up to November 2015. This Campbell Systematic Review was published in October 2017. Executive summary/Abstract Background There is an increasing focus on mind‐body interventions for relieving stress, and improving health and quality of life, accompanied by a growing body of research trying to evaluate such interventions. One of the most well‐known Programs is Mindfulness‐Based Stress Reduction (MBSR), which was developed by Kabat‐Zinn in 1979. Mindfulness is paying attention to the present moment in a non‐judgmental way. The Program is based on old contemplative traditions and involves regular meditation practice. A number of reviews and meta‐analyses have been carried out to evaluate the effects of meditation and mindfulness training, but few have adhered to the meta‐analytic protocol set out by the Cochrane Collaboration and Campbell Collaboration, or focused on MBSR only. The first edition of this review was published in 2012 with a literature search done in 2010, comprising 31 studies. As the field is rapidly developing, an update is called for. Objectives To evaluate the effect of Mindfulness‐Based Stress Reduction (MBSR) on health, quality of life and social functioning in adults. Search methods The following sources were searched, most recently in November 2015: PsycINFO (Ovid), MEDLINE (Ovid), EMBASE (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (Ebsco), Ovid Nursing Full Text Plus (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), British Nursing Index, (ProQuest), Eric (ProQuest), ProQuest Medical Library, ProQuest Nursing & Allied Health Source, ProQuest Psychology Journals, Web of Science, SveMed+, Social Services Abstracts, Sociological Abstracts and International Bibliography of Social Sciences. Selection criteria The review included randomised controlled trials (RCTs) where the intervention followed the MBSR protocol developed by Kabat‐Zinn, allowing for variations in the length of the MBSR courses. All target groups were accepted, as were all types of control groups, and no language restrictions were imposed. Data collection and analysis Two reviewers read titles, retrieved studies, and extracted data from all included studies. Standardized mean differences (as Hedges’ g) from all study outcomes were calculated using the software Comprehensive Meta Analysis. The meta‐analyses were carried out using the Robumeta Package within the statistical program R, with a technique for handling clusters of internally correlated effect estimates. We performed separate meta‐analyses for MBSR compared to either waitlists or treatment as usual (WL/TAU – named inactive), and for MBSR compared to control groups that were offered another active intervention. Results The review identified 101 RCTs including the 31 from the first review, with a total of 8,135 participants. Twenty‐two trials included persons with mild or moderate psychological problems, 47 targeted people with various somatic conditions and 32 of the studies recruited people from the general population. Seventy‐two studies compared MBSR to a WL/TAU control group, while 37 compared MBSR to an active control intervention. Seven studies compared MBSR to both a WL/TAU condition and to an active control group. Ninety‐six studies contributed to the meta‐analyses (based on information from 7,647 participants). Two thirds of the included studies showed a considerable risk of bias, and risk of bias was higher among studies with inactive than active control groups. Post‐intervention Hedges’ g effect sizes for MBSR versus WL/TAU for the outcome measures of mental health, somatic health, and quality of life including social function were, respectively, 0.54 (95% CI 0.44, 0.63), 0.39 (95% CI 0.24, 0.54), and 0.44 (95% CI 0.31, 0.56). Some funnel‐plot asymmetry points to a small degree of underreporting of negative trials. Heterogeneity was moderate for mental health and quality of life, and high for somatic health. Assuming a favourable outcome for 50% of the control group, the main finding of an effect size of 0.54 for improving mental health corresponds to a 65% chance that a random person from the treatment group will have a higher score than a person picked at random from the control group (probability of superiority). Another way of putting it, is that in order to have one more favourable mental health outcome in the treatment group compared to the control group at end of intervention, five people need to be treated (NNT=4.9, 95% CI 4.2, 5.9). Thus, if 100 people go through the treatment, 21 more people will have a favourable outcome compared to if they had been put on a wait‐list or gotten the usual treatment. For 21 studies with follow‐up data, the effect size was generally maintained at follow‐up (1–32 months). For the comparison of MBSR versus alternative psychosocial interventions at post‐intervention there was a small, statistically significant difference in favour of MBSR improving mental health with a Hedges’ g effect of 0.18 (95% CI 0.05, 0.30), and MBSR was not more effective than other active interventions on outcome measures of somatic health, 0.13 (95% CI ‐0.08, 0.34) and quality of life (including social function), 0.17 (95% CI ‐0.02, 0.35). Heterogeneity was low for mental health, moderate for quality of life and high for somatic health, and there was no funnel‐plot asymmetry. Assuming a favourable outcome for 50% of the control group, the main finding of an effect size of 0.18 for improving mental health corresponds to a 57% chance that a random person from the treatment group will have a higher score than a person picked at random from the control group and the NNT=14, 95% CI 8, 50). Since the measure of mental health includes outcomes from a larger proportion of the included studies compared to somatic health or quality of life, it is a more robust measure for the effect of the MBSR intervention. It is therefore treated as the main primary outcome for the meta‐analyses. For all comparisons effect sizes were fairly similar across the range of target groups and the effects were generally maintained at follow‐up (1–34 months). Effect sizes for measures of mental health were not particularly influenced by length of intervention, attendance or self‐reported practice, but they were strongly correlated to the effects on measures of mindfulness, indicating that the effects of the MBSR intervention may be related to the increase in self‐reported mindfulness. Sensitivity analyses with exclusion of studies with exceptional findings did not substantially change the results. A majority of studies suffered from risk of bias, and studies of higher quality reported lower effects than studies with low quality. We found no reports of side‐effects or costs in any of the trials. The overall quality of the evidence was moderate, indicating moderate confidence in the reported effect sizes. However, further research could impact on our confidence in the estimate of effect and may change the estimate. Authors’ conclusions MBSR has moderate effect on mental health across a number of outcome measures, for a range of target groups and in a variety of settings, compared to a WL or TAU control group. NNT was 4.9 (95% CI 4.2, 5.9) post‐intervention; on par with other well‐established interventions in the health service. The effect on somatic health is smaller, but still statistically significant. MBSR also seems to improve measures of quality of life and social function when compared to inactive control groups. MBSR improved mental health compared to other active psychosocial interventions, with a NNT = 14 (95% CI 8, 50), and had a similar effect on improving somatic health, and quality of life and social function. For all comparisons, the effects were maintained at follow‐up and correlated to effects on mindfulness. The quality of the evidence was moderate and should be improved in future studies. There were many studies with considerable bias, and heterogeneity was mostly moderate. In addition, there is indication of underreporting of negative studies when MBSR was compared to inactive controls. These factors might have influenced the results found. MBSR might be an attractive option to improve health, handle stress, and cope with the strains of life. Ways to further strengthen the effect should be sought. All new trials should include measures of mindfulness and explore moderators and mediators of effects. New studies should register study protocols and adhere to guidelines for reporting of randomized controlled trials.