Abstract
Adolescence represents a crucial period of development, during which exposure to stress can significantly impact mental and physical health. As such, school based psychoeducational interventions aimed at reducing stress may hold promise for promoting adolescents’ wellbeing. In the current study, a literature review was conducted using PubMed and PsychInfo databases to evaluate school-based psychoeducational interventions that target sub-clinical anxiety and stress in healthy adolescents. Eleven studies met the inclusion criteria, comprising six primary and five secondary studies. Cognitive-behavioural therapy demonstrated significant reductions in anxiety symptoms and improvements in emotional regulation. Mindfulness-based interventionsalleviated physiological stress, while physical activity programs such as yoga, showed potential in improving psychological well-being, albeit with limited evidence. . Findings on the duration of interventions were mixed, with some meta-analyses indicating larger effects for longer or higher intensity programs, while limited evidence suggests caregiver involvement may enhance outcomes. Future research should focus on evaluating the long-term effectiveness of these interventions and examining their applicability across diverse cultural and socioeconomic contexts. Although harms were not identified within the studies included in this review, other research has reported potential unintended effects of school-based psychological interventions in specific subgroups and therefore cautious implementation with routine monitoring is recommended.
Plain Language Summary
Many teenagers experience stress and anxiety that do not always meet clinical levels but can still affect their daily lives and long-term health. Researchers conducted a review of studies examining school-based psychoeducational programs aimed at reducing these issues in adolescents. They focused on various strategies, including cognitive-behavioral therapy (CBT), mindfulness-based interventions (MBI), and physical activities such as yoga. The studies showed that school-based psychoeducational programs, when offered in school settings, reduced mild anxiety symptoms and encouraged better emotional control. Students who participated in mindfulness approaches reported feeling calmer, developed healthier coping habits, and sometimes showed reduced physiological signs of stress. Although physical activities like yoga appeared to help students feel better about themselves, further research is needed to confirm these benefits. The effectiveness of these interventions did not depend on how long they lasted. Rather, studies indicated that support from parents, combined with the program’s techniques, improved the overall success of each approach. In some cases, when parents and caregivers joined the activities or received guidance on how to assist their teenagers at home, students displayed stronger results. Schools serve as important places for these programs because they reach many adolescents in familiar environments. According to the review, introducing psychoeducational interventions in schools is a promising way to decrease mild anxiety and stress in teenagers, while potentially preventing more serious problems that can appear during adulthood. More investigations are needed on how these methods hold up over time and how they can be applied in different cultural and economic settings. Overall, school-based interventions that involve CBT, mindfulness practices, or physical activities can help prevent and manage sub-clinical anxiety and stress in teenagers. Adding family.
Introduction
Adolescence is the transitional phase of growth and development between childhood and adulthood, characterized by significant changes in biological, psychosocial dynamics, cognition and emotions (National Academies of Sciences, Engineering, and Medicine et al., 2019; Sawyer et al., 2018). This period offers a window of opportunity for developing social, physical and emotional coping strategies, which are crucial for mental health. In addition, during this period, adolescents form their personalities and acquire essential skills to manage future stressful situations (Sawyer et al., 2018; World Health Organization, 2021). A supportive environment provided by family, school, and the community is essential for enhancing well-being and enabling individuals to confront modern societal challenges (World Health Organization, 2021).
The World Health Organisation defines stress as a state of worry or mental tension caused by challenging situations (World Health Organization, 2023). It is a physiological or psychological response to internal or external stressors that urge individuals to address and confront challenges during their life (APA, 2022). While a certain degree of stress is normal and necessary for daily functioning, excessive stress has a significant negative impact on core physiological systems. It considerably affects brain function, including memory, cognition and learning, and compromises the cardiovascular, endocrine and gastrointestinal systems (Yaribeygi et al., 2017). Increased stress manifests through a variety of physical symptoms including headaches, stomach aches, or limiting wellness and affecting quality of life. Chronic stress constitutes a major risk factor for diseases affecting the cardiovascular system, cancer and mental health disorders and leads to immunosuppression (Dhabhar, 2014).
The terms ‘stress’ and ‘anxiety’ are often used interchangeably, though they refer to distinct phenomena. According to the American Psychological Association (APA, 2022), both are emotional reactions, but stress is usually triggered by an external factor which can be short-term or long-term. Adolescents experiencing stress may exhibit mental and physical symptoms, including irritability, anger, fatigue, muscle pain, digestive issues, and sleep disturbances. Conversely, anxiety involves persistent, excessive worry without an external factor, with symptoms similar to stress including insomnia, difficulty concentrating, fatigue, muscle tension, and irritability. Mild forms of both conditions can be managed with coping strategies but may escalate into chronic stress and anxiety disorders if not managed in time (APA, 2022; Putwain, 2007;). In addition to clinically diagnosed, sub-clinical anxiety exists characterised by an individual experiencing worry for a duration of at least three months, accompanied by symptoms such as restlessness, fatigue, concentration difficulties, irritability, muscle tension, and sleep disturbances (Volz et al., 2021).
Globally one in seven adolescents, (ages 10 to 19) experiences a mental health condition (Global Burden of Disease Child and Adolescent Health Collaboration, 2017; World Health Organization, 2021). It is estimated that 3.6% of adolescents aged 10–14 and 4.6% aged 15–19 experience anxiety disorders (Global Burden of Disease Child and Adolescent Health Collaboration, 2017; World Health Organization, 2021). For adolescents, stress is associated with lower productivity and poorer academic performance (Obermeier et al., 2023) and increases the risk of developing disorders including depression, anxiety, substance use and cardio-metabolic disorders in adulthood (Lee et al., 2021).
Diagnosing stress and anxiety in adolescents is challenging, as these emotions may be confused with typical fears and worries, leading to underdiagnosis and untreated cases (Baourda et al., 2021). Considering the plasticity of adolescence and its importance in human development as well as the importance of coping mechanisms to regulate stress and anxiety during this period and later in adulthood, interventions aimed at promoting mental wellbeing by reducing stress and anxiety are of utmost importance. Research so far indicates that interventions need to focus on enhancing emotional regulation, building resilience for managing challenging situations and adversities, and promoting supportive social environments (World Health Organization, 2021). Documented interventions include cognitive behavioural therapy (CBT), mindfulness practices, family-based programs and social skills training, all aimed at promoting the mental wellbeing of adolescents while mitigating the long-term effects of chronic stress and anxiety (Clarke et al., 2021).
One major category is psychoeducational interventions which are structured approaches that aim to educate individuals about psychological issues, enhancing understanding and coping strategies through information and skills training (Suzuki & Tanoue, 2020). The goal is to empower individuals to manage their mental health, reduce symptoms, and tackle challenges (Lukens & McFarlane, 2004; Morgado et al., 2021; Ramaiya et al., 2022; Wolgensinger, 2015). In schools, psychoeducational interventions could potentially be effective, as they integrate into daily adolescent life and leverage the supportive environment of the educational system (World Health Organization, 2021).
Psychoeducational interventions can draw on various disciplines, such as education, psychotherapy (e.g. Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), rational emotive behavioral therapy (REBT)) mindfulness-based interventions (MBI) (e.g. meditation and breathing exercises), cognitive psychology (e.g. self-efficacy or the confidence in one’s ability to carry out a behaviour), positive psychology (e.g. gratitude), physical education (e.g. exercise regimes), nutrition (e.g. healthy eating), sociology and social psychology (e.g. peer and parental guidance) (Morgado et al., 2021; Ramaiya et al., 2022; Wolgensinger, 2015).
CBT is a structured, goal-oriented psychotherapy that targets maladaptive thoughts and behaviours using techniques such as exposure, behavioural activation, and cognitive restructuring. DBT is a cognitive behavioural treatment grounded in the biosocial theory of emotion dysregulation. It combines change strategies with acceptance-based strategies within a dialectical framework and is delivered through coordinated modes, individual therapy, group skills training, between-session coaching, and a therapist consultation team. Core skills include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, with adolescent adaptations that incorporate caregiver participation and “walking the middle path” skills (Ramaiya et al., 2022; Wolgensinger, 2015). These psychotherapeutic interventions and other methods including exercise and school-based psychoeducation aim to enhance adolescent mental well-being (Morgado et al., 2021). By combining psychoeducation with psychotherapeutic techniques, schools can offer interventions that aim to promote a holistic approach to social, physical and mental well-being of adolescents (Morgado et al., 2021).
The aim of this narrative review is to present the latest evidence on school-based psychoeducational interventions, focusing on the effectiveness of empowering adolescents with coping skills for ‘sub-clinical anxiety’ and ‘stress’ across various geographical locations and school environments.
Methods
A search was conducted in PubMed and PsychInfo databases to retrieve primary and secondary studies investigating school-based psychoeducational interventions implemented to empower adolescents with coping skills to deal with ‘sub-clinical anxiety’ and ‘stress’ in different geographical locations and school environments.
The Inclusion criteria were as follows. • Studies discussing school-based psychoeducational interventions in healthy (without any non-communicable or chronic conditions such as type I diabetes, asthma or mental health disorders) adolescents, aged 12-18 years, irrespective of sex or gender, and from any geographical or ethnic background. • Outcomes included sub-clinical anxiety and/or stress. Studies with no evidence on whether anxiety was at sub-clinical level at baseline were excluded. • Both primary (quasi experimental, non-randomised trials and randomised controlled trials) and secondary (systematic reviews and meta-analyses) studies were eligible, irrespective of overlap. • Only articles written in the English language, published between 2014 to April 2024, and with full text available, were included.
The Search strategy in the two databases is provided in Supplemental Table 1.
Results
Six primary studies met the inclusion criteria (two were quasi-experimental studies, one was a non-randomized controlled trial, and the three remaining were randomized controlled trials). Five studies were secondary studies (1 systematic review and 4 meta-analyses).
Primary Studies
Descriptive Characteristics of Primary Studies (Quasi Experimental, Non-randomized Controlled Trials and Randomized Controlled Trials) Investigating the Role of Psychoeducational Interventions on Sub-clinical Anxiety and Stress in Adolescents
CAMM: children and adolescent mindfulness measure; MSQ: manipal stress questionnaire; NIMHANS: national institute of mental health and neuro sciences; N/A: not available; PSS: perceived stress scale; SCS: self-compassion scale-short form; SD: standard deviation; SLSSS: student life satisfaction scale. DERS-SF: difficulties in emotion regulation scale-short form; Y.O.G.A.: your own greatness affirmed; POMS-A: profile of mood states-adolescents. CBT: cognitive behavioral therapy; CI: confidence interval; DASS-21: depression anxiety stress scale; DBT: dialectical behavioral therapy; MBI: mindfulness-based intervention; SD: standard deviation.
Quasi Experimental Studies
Two studies utilised a pretest-post-test quasi experimental design (Bluth et al., 2015; Roy et al., 2016) (Table 1).
Bluth et al. (2015) conducted a pilot study in the U.S. with 28 adolescents to assess the effects of a mindfulness-based intervention (MBI) on emotional well-being. Participants attended six weekly 90-min sessions using the “Learning to Breathe” curriculum. Outcomes measured included perceived stress, mindfulness, life satisfaction, and self-compassion. While self-compassion significantly improved, decreases in perceived stress (from 28.32 to 25.39, Hedge’s g = 0.34) were not statistically significant. Notably, self-compassion and life satisfaction showed inverse correlations with perceived stress, suggesting that improvements in these areas may reduce stress. The study highlights the potential of mindfulness to enhance emotional well-being, but larger studies are needed to confirm these findings.
The pre-post study by Roy et al. (2016) assessed the impact of life skills training on reducing stress among adolescents in India. The study involved 42 boys from the 9th and 10th grades, participating in a structured seven-day program. Each session lasted 45-60 minutes and aimed at enhancing stress management and coping skills following the National Institute of Mental Health and Neurosciences (NIMHANS) model. Stress levels were measured using the Manipal Stress Questionnaire before, immediately after, and one and three months following the intervention. Statistical analysis demonstrated a significant reduction in mean stress levels between baseline and one- and three-months follow-up (p < 0.05). The program was considered feasible and was well-received by participants. The authors proposed that group-based stress management programs may be beneficial in reducing stress levels among adolescents.
Non-Randomized Trials (nRCT)
McMahon et al. (2021) investigated the effects of Kundalini Yoga on emotional dysregulation and psychological functioning in U.S. adolescents. The study involved a six-week program with twice-weekly sessions, focusing on postures, breathing, and meditation. Participants included students from four schools, with the control group engaging in alternative extracurricular activities. Psychological outcomes were assessed using the Depression, Anxiety, and Stress Scale (DASS-21) and the Profile of Mood States for Adolescents (POMS-A). While no significant changes in depression, anxiety, or stress were found on the DASS-21, reductions in emotional dysregulation, anger, and fatigue were observed on the POMS-A. Effects varied significantly across schools; in one school, intervention participants showed notable improvements in anxiety, stress, and depression, while another school reported increased anxiety levels in the intervention group. These variations were attributed to differences in program implementation and environmental factors, emphasizing the importance of contextual influences on the effectiveness of Kundalini Yoga for stress and emotional regulation.
Randomized Control Trials (RCTs)
Our search identified 3 randomized controlled trials (RCTs) (Liu et al., 2023; Vogelaar et al., 2024; Wergeland et al., 2023) (Table 1).
Wergeland et al. (2023) conducted a randomized waitlist-controlled trial of 320 youths in Norway who were engaged in either a 10-session or a 5-session CBT group intervention. The study aimed to identify the factors, such as youth and parental characteristics, that predict the benefits of such intervention for youth subclinical anxiety. The outcomes were measured by changes in self-reported anxiety and depression symptoms at post-intervention and at one-year follow-up. Anxiety was measured by various measurements including the Spence Children’s Anxiety Scale, the Child Anxiety Life Interference Scale and the DASS-21 scale which indicated subclinical anxiety. In addition, the study excluded adolescents who received other mental health services. The findings highlighted the role of parental perceptions and attitudes as predictors of the effectiveness of the intervention. Specifically, higher parent-reported credibility and expectancy of the intervention was associated with larger youth-reported anxiety symptom improvement (β = −0.46, p = 0.003). Parent-reported youth impairment from anxiety showed improvement (β = −0.76, p < 0.001) and higher parent-reported credibility and expectancy resulted in larger symptom improvements (β = −0.44, p = 0.001). The significant changes were notable at post-intervention, but no improvement was found at 1-year follow-up.
Liu et al. (2023) conducted a clustered RCT in China to assess the effectiveness of mindfulness-based interventions (MBIs) in reducing psychological stress and enhancing resilience among adolescents. The study involved 92 students in the intervention group, who attended 10 weekly 45-min mindfulness sessions led by trained instructors, and 97 control students following the standard school program. Psychological stress, trait mindfulness, and resilience were measured using validated questionnaires. The results showed significant reductions in stress levels (pre-test mean: 1.76; post-test mean: 1.30, p < 0.05) and improvements in psychological resilience within the intervention group. A significant interaction effect between the intervention and control groups was observed, with a large effect size (Cohen’s d = 1.04, 95% CI: 0.72–1.35). These findings suggest that MBIs may effectively reduce stress in adolescents by strengthening psychological resilience.
In a clustered RCT conducted by Vogelaar et al. (2024), the researchers evaluated the effectiveness of a psychoeducational program called “Stress Lessons” on 1613 adolescents in the Netherlands. The intervention consisted of 3 lessons, delivered once per week for 45 minutes and aimed to reduce overall and school stress and increase knowledge about stress. The control group did not receive the lessons during the intervention. To assess the intervention’s impact, the study employed the Stress Knowledge Questionnaire and the short Dutch version of the Adolescent Stress Questionnaire at both pre- and post-intervention stages. The results for the experimental group showed a significant increase in stress knowledge, with a mean difference of 0.41 and an effect size (d) of 0.35, indicating small to medium effects (p < 0.001). However, no significant changes were observed in the overall and school-related stress in the experimental group (p = 0.34 and p = 0.13 respectively). Interestingly, the control group reported a decrease in the overall and school-related stress (p = 0.004 and p = 0.01 respectively). These findings suggest that while the “Stress Lessons” program successfully increased stress knowledge, it did not effectively reduce stress levels, contrasting with the control group outcomes.
Secondary Studies
Systematic Reviews and Meta-Analyses Investigating the Role of Psychoeducational Interventions on Sub-clinical Anxiety and Stress in Adolescents
BP: blood pressure; CBT: cognitive-behavioural therapy; MBI: mindfulness-based intervention; N/A: not available; PTSD: post-traumatic stress disorder; RCT: randomized controlled trial.
Systematic Review
Jagiello et al. (2024) conducted a systematic literature review to evaluate the effectiveness of high-school-based programs aimed at decreasing or preventing stress related to academic performance among high school students. The review encompassed 31 studies across 13 countries. The intervention programs were categorized based on type (e.g. Expressive Writing, Mindfulness and Mediation), format (universal or targeted) and delivery method (e.g. face-to-face, phone app). Their findings highlighted that CBT approaches were particularly effective with 13 out of 17 studies reporting a significant reduction in academic stress and anxiety among participants. Both targeted programs aimed at students experiencing elevated symptoms of subclinical anxiety or stress and universal programs aimed at students with varying stress levels were found to be beneficial. However, the review also noted several methodological limitations in the studies, including small sample sizes and the use of inactive control groups. These limitations suggest the need for more rigorous research to fully understand the effectiveness of these interventions.
Meta-Analyses
The meta-analysis by van Loon et al. (2020), aimed to evaluate the effectiveness of school-based intervention programs in reducing psychological stress among adolescents and to examine factors influencing their effectiveness. The multilevel meta-analysis incorporated data from 54 studies with a total of 16,475 participants across various countries. Using a three-level random effects meta-analytic model, the study analysed interventions that targeted adolescent stress, required control groups, and pre- and post-intervention assessments. The findings revealed a statistically significant moderate overall effect size for school-based interventions in reducing psychological stress (d = 0.543, p < 0.001). The interventions (Table 2) were particularly effective in reducing school-related stress compared to social stress, remained effective in the longer term, and were more effective in selected student groups. These results suggest that school-based interventions can be instrumental in alleviating stress among adolescents, especially when focused on school-related stressors and tailored to students identified as having higher stress levels.
In another study Van Loon et al. (2022) investigated the impact of school-based interventions on physiological stress indicators in adolescents, focusing on cortisol, blood pressure (BP), and heart rate (HR)/heart rate variability (HRV). The analysis included 30 studies with a total of 4,460 participants aged 10 to 18 from various countries. A three-level meta-analytic model was used to analyze studies that featured school-based interventions aimed at improving psychosocial functioning and reported at least one physiological stress-related outcome. The results demonstrated a small but significant overall effect in reducing BP (d = −0.173, p = 0.014). However, no significant effect was observed for HR/HRV (d = 0.134, p = 0.209), while for cortisol levels a meta-analysis was not conducted due to methodological heterogeneity across the studies Programs that incorporated mindfulness, meditation, or relaxation techniques and those of higher intensity were associated with larger effects. Notably, significant effects in BP were found only in (cluster) RCTs, not in quasi-experimental designs. These findings highlight the potential of school-based interventions to positively influence physiological stress responses in adolescents.
The meta-analysis by Fulambarkar et al. (2023) evaluated the effectiveness of MBI longer than four weeks in addressing stress, depression, and anxiety among adolescents in school settings. The analysis included nine RCTs with a total of 5,046 adolescents. The results indicated a significant improvement across symptoms of stress, depression, and anxiety, with a significantly small overall effect size (Hedge’s g = 0.33, p < 0.01). Subgroup analysis showed a significant and moderate effect size for perceived stress (g = 0.55, p < 0.01) but the latter was not observed for depression and anxiety. The results were significant when compared with inactive controls such as those on a waitlist or engaged in usual curricular lessons. However, the effects were not significant when the intervention groups were compared with active controls which included students engaged in interventions such as yoga, relaxation and substance abuse prevention. These findings suggest that while MBI can be effective in reducing perceived stress, their comparative benefits may be less pronounced when measured against other active health interventions.
In their meta-analysis, Ng et al. (2024) evaluated the effectiveness of stress management interventions among U.S. high school students. The analysis included 25 studies involving a total of 3,100 high school students aged 12 to 20 years. The pooled effect size for stress reduction across these studies was calculated as g = −0.36 (p < 0.0001), indicating a small although significant reduction in stress among the adolescents. The interventions also demonstrated small significant effects in reducing anxiety (g = −0.31; p < 0.0001) and depression (g = −0.23; p < 0.0001). Long-term follow-up revealed a more substantial reduction in perceived stress, with an effect size of g = −0.77 (p = 0.019). However, long-term effects on anxiety (g = −0.098; p = 0.466) and depression (g = −0.19; p = 0.05) were minimal. Longer interventions, lasting more than eight weeks, were particularly more effective in reducing anxiety depression compared to shorter interventions (g = −0.36 vs. g = −0.17; p = 0.026) These findings suggest that more extended interventions in duration may provide greater benefits in managing stress, anxiety, and depression among high school students.
Discussion
The primary aim of this review was to identify effective school-based interventions that could be integrated into school curricula to mitigate sub-clinical anxiety and stress among adolescents. The findings from the included studies provide valuable insights with numerous implications for both practice and future research (Tables 1-2).
CBT and MBI
In this review, one school-based CBT randomized controlled trial reported short-term reductions in subclinical anxiety; however, effects were not maintained at 12 months (Wergeland et al., 2023). Furthermore, in this study higher parental credibility and expectancy were associated with better outcomes, which underscores the importance of parental perceptions and engagement. In addition, the lack of sustained effectiveness indicates a need for longer-term strategies, for example, scheduled booster sessions, to maintain benefits (Wergeland et al., 2023). Considered alongside the secondary literature in our review, which provides preliminary evidence suggesting that CBT may be beneficial (Jagiello et al., 2024; Ng et al., 2024), these findings point to the need for adequately powered school-based trials with extended follow-up and explicit parental involvement to determine effectiveness in school settings.
Similarly, MBI, have emerged as promising approaches. Evidence from Liu et al. (2023) and the meta-analysis of Fulambarkar et al. (2023) underscore their efficacy in reducing stress and fostering resilience. These interventions show clear potential for enhancing long term emotional well-being and highlight the need for further exploration into culturally and individually tailored adaptations to ensure equitable and inclusive access for diverse adolescent populations.
Physical Activity
Physical activity interventions, such as yoga, also present opportunities to enhance psychological health among adolescents. Research by McMahon et al. (2021) suggests a modest but positive impact of physical activity on psychological health, but the limited number of studies and variations in program design hamper the ability to draw firm conclusions. However, the variability in program implementation, as observed across different schools, underscores the importance of standardizing intervention protocols to maximize benefits. Programs must also address practical issues, such as limited time or resources in schools, by designing accessible, time-efficient interventions that can easily integrate into the existing curriculum. Despite these known challenges, the role of physical activity in reducing stress and sub-clinical anxiety warrants further investigation, especially in resource-constrained settings where cost-effective strategies are necessary.
Parental Involvement
Parental involvement emerged as another important factor influencing intervention outcomes, though the evidence remains mixed. Some studies, such as Wergeland et al. (2023), indicate that parental credibility and expectations significantly contribute to the success of school-based CBT interventions, suggesting that parents play an important role as mediators of success. Involving parents through workshops, strategy-sharing sessions, or take-home materials may help amplify positive intervention outcomes. However, barriers to parental engagement—such as time constraints or caregiver strain—must be carefully addressed in the design of future programs.
Intervention Duration and Delivery
A significant observation across the reviewed studies is the mixed findings regarding the duration of interventions. Mixed findings suggest that the quality of intervention sessions may surpass the importance of their quantity. For example, studies such as Wergeland et al. (2023) advocate for the importance of well-structured, shorter sessions that balance comprehensiveness with practical time constraints in schools. Similarly, the “Stress Lessons” program evaluated by Vogelaar et al. (2024) demonstrates that short-term interventions can improve stress knowledge, though they may have limited immediate impact on reducing perceived stress.
Strengths
Our narrative review provides an integrative analysis of various school-based interventions from various geographic locations and educational environments. By focusing on a range of interventions, including CBT, MBIs, and physical activity, the review offers a comprehensive perspective on strategies to reduce sub-clinical anxiety and stress among adolescents. Moreover, the inclusion of recent studies ensures that the findings remain relevant to current academic and clinical practices. Emphasizing interventions aimed at adolescents with sub-clinical anxiety levels at baseline is particularly significant, given this critical developmental period’s potential for long-term mental health benefits. The findings contribute practical recommendations for integrating effective interventions into school curricula, offering insights that may inform policy and practice.
Limitations
The findings of this review highlight certain limitations inherent in the included studies. The studies analyzed in the review have significant differences that makes comparison between studies difficult. Furthermore, a prevalent issue is the small sample size of most primary studies and the variability in study designs, such as the use of different methodologies like RCTs versus quasi-experimental studies, which introduces heterogeneity and complicates direct comparisons.
One critical limitation is the reliance on the DASS-21 as an outcome measure in several studies. While the DASS-21 is a robust tool for assessing general psychological stress, it is less appropriate for measuring child-specific anxiety symptoms, potentially leading to an underestimation of intervention effects. Future research should consider employing validated youth-specific tools, such as the Revised Child Anxiety and Depression Scale (RCADS) or the Screen for Child Anxiety Related Emotional Disorders (SCARED), to address this gap (Baourda et al., 2021; Friedberg et al., 2022).
Another limitation is the lack of consistency in follow-up periods for assessing long-term outcomes. Many of the studies focused on short-term outcomes, offering limited insights into the long-term efficacy and sustainability of the interventions examined. Long-term studies are, therefore, essential to better understand whether initial gains persist over time. Furthermore, a limitation of this review is that our search strategy focused on intervention effectiveness and may not have captured studies primarily reporting harms or adverse effects. Future systematic reviews could expand the scope to critically evaluate both benefits and risks. Finally, differences in cultural and socioeconomic contexts, as well as variations in program implementation, may limit the generalizability of findings. . Differences in intervention implementation, such as whether programs are delivered by teachers or external facilitators, lead to varied outcomes, making it challenging to draw definitive conclusions about the effectiveness of specific interventions. Moreover, external factors, including parental involvement and school environments, are not consistently explored or controlled, affecting the perceived intervention effectiveness. Addressing these variables systematically in future research will enhance the robustness of findings.
Practice Implications
This review highlights that school-based psychoeducational interventions can be beneficial for mitigating stress and sub-clinical anxiety in adolescents, particularly through evidence-based approaches such as CBT and MBI. The latter are particularly effective approaches that improve emotional regulation and psychological resilience. Schools should focus on incorporating these methods into their curricula, with clear emphasis on practical feasibility and accessibility for adolescents.
While our review highlights the benefits of school-based interventions, it is important to acknowledge potential risks. Recent research, such as Guzman-Holst et al. (2025) has documented instances of iatrogenic harm, among certain subgroups including individuals deemed at high risk of mental health problems, male participants, and younger children and children eligible for free school meals. Approximately 8.93% of these programs were associated with negative outcomes, such as increased anxiety or worsened well-being. These findings underscore the need for thorough monitoring and rigorous design to ensure programs are both effective and safe (Guzman-Holst et al., 2025). Notably, our literature review focused only on healthy adolescents without mental health disorders and did not provide evidence for harmful effects on the participants (Tables 1 and 2).
The findings of this review also highlight the importance of parental involvement. Evidence from Wergeland et al. (2023) and other studies underscores the role of parents in amplifying the effectiveness of school-based interventions. Schools should actively engage parents through take-home workshops, newsletters, and shared resources to promote home-based reinforcement of strategies taught during interventions. Structured parental participation could further support adolescents in maintaining long-term benefits from these programs.
Additionally, this review supports the inclusion of physical activity interventions as part of a holistic approach to promoting adolescent mental health. While yoga programs, as evaluated by McMahon et al. (2021), have shown potential for improving psychological health, more rigorous studies are needed to standardize these practices and evaluate their efficacy across broader populations.
Lastly as suggested by Friedberg et al. (2022), integrating creative and engaging formats into psychoeducational interventions—such as multimedia tools, interactive simulations, or arts-based therapies—could improve outcomes by enhancing engagement and retention.
Implications for Research
Future research should aim to address several knowledge gaps identified in this review. First, the development of culturally tailored interventions is crucial to ensure equitable and inclusive access to effective mental health interventions. Standardized tools that factor in cultural and linguistic variations, as well as interventions designed for low-resource settings, are needed to expand the reach and utility of school-based programs. Second, longitudinal studies should be prioritised to evaluate the sustainability of intervention outcomes over extended periods. This will provide a clearer understanding of whether initial improvements in emotional regulation and resilience persist into adulthood.
Innovative delivery methods may improve accessibility and engagement, especially in underserved areas. Technological innovations, such as mobile applications or virtual reality platforms, may also play a role in enhancing accessibility and engagement with school-based interventions. These tools could allow programs to extend beyond the physical classroom and provide ongoing support for adolescents who may not have access to in-person facilitation.
Alongside this, evaluation frameworks combining qualitative and quantitative assessments can provide a comprehensive view of intervention effectiveness. In addition, a focused examination of parental involvement’s role and its potential to enrich intervention outcomes is crucial. Insights from existing studies suggest parents’ engagement could significantly amplify the benefits of school-based programs. Finally, future research should incorporate evaluations of potential adverse outcomes alongside benefits to ensure a balanced understanding of intervention impacts.
Addressing these knowledge gaps would significantly advance the field, improving the design, implementation, and evaluation of school-based mental health strategies to promote the well-being of adolescents globally.
Conclusion
This review highlights the substantial potential of school-based psycho-educational interventions in mitigating sub-clinical anxiety and stress among adolescents. CBT and MBI consistently stand out as promising approaches, not only in reducing symptoms of sub-clinical anxiety and stress but also in enhancing resilience and emotional well-being. Physical activity interventions show promise, though further investigation is needed to standardize and evaluate their efficacy. Additionally, the review underscores the importance of factors such as parental involvement and well-structured session delivery in optimizing intervention outcomes.
Future research should focus on tailoring interventions to diverse cultural contexts, exploring their long-term impact, and leveraging technological tools to expand their reach. Although adverse events were not reported in the studies included in this review, other research has documented potential unintended effects of school-based psychological interventions; therefore, programs should be implemented cautiously with routine outcome monitoring, opt-out options, and clear referral pathways. By addressing these areas, school-based programs can play a crucial role in enhancing mental health and resilience among adolescents, ultimately contributing to their overall well-being.
Supplemental Material
Supplemental material - Effectiveness of School-Based Psycho-Educational Interventions in Preventing Sub-clinical Anxiety and Stress in Adolescents
Supplemental material for Effectiveness of School-Based Psycho-Educational Interventions in Preventing Sub-clinical Anxiety and Stress in Adolescents by Alexia Papageorgiou, Panayiota Andreou, Zoi Savva, Konstantinos Kossenas, Annalisa Quattrocchi, Haris Charalambous, Christiana Demetriou, Elena Philippou, Ourania Kolokotroni, Koralia Michail, Christiana Nicolaou, Constantina Constantinou in Clinical Child Psychology and Psychiatry
Footnotes
Acknowledgements
The authors would like to express their gratitude to their institutions for the support provided throughout the course of this research. This work would not have been possible without the resources and facilities offered by the respective institutions.
Ethical Considerations
This paper is a narrative review and therefore there was no need to submit a protocol for ethical approval.
Consent to Participate
This paper is a narrative review and therefore no patients were involved in the current paper and there was no need to receive patient consent.
Author Contributions
The conceptualization of the study was a collaborative effort led by AP, PA, AQ, HC, CD, EP, OK, KM, CN, and CC. Methodological design and planning were carried out by AP, PA, ZS, KK, AQ, CD, EP, OK, KM, CN, and CC. Data curation and investigation were performed by AP, PA, ZS, KK, AQ, and CC, while formal analysis of the data was led by AP, PA, AQ, and CC. The supervision of the study was conducted by AP, PA, and CC, ensuring that all aspects met the highest standards of quality and rigor. Visualization of the data and results was managed by AP, PA, AQ, and CC. Project administration was carried out by CC, who oversaw timelines and resource allocation. The original draft of the manuscript was primarily written by AP, PA, ZS, KK, AQ, and CC. Subsequent review and editing involved contributions from all listed authors, including HC, CD, EP, OK, KM, and CN, ensuring the manuscript was refined and met publication standards. The authors have collaboratively brought distinct expertise to the project while maintaining a cohesive and interdisciplinary approach throughout the study. Key to Acronyms: AP: Alexia Papageorgiou; PA: Panayiota Andreou; AQ: Annalisa Quattrocchi; HC: Haris Charalambous; CD: Christiana Demetriou; EP: Elena Philippou; OK: Ourania Kolokotroni; KM: Koralia Michail; CN: Christiana Nicolaou; CC: Constantina Constantinou; ZS: Zoi Savva; KK: Konstantinos Kossenas.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
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