Effects of a Universal Classroom-Based Prevention Program (Pax Good Behavior Game) on Children’s Mental Health in Estonia

Introduction: There is a high and increasing rate of mental and behavioral health problems among children in Europe (WHO, 2018). School is one important setting for prevention; positive school environment and early interventions can protect mental health during childhood. Good Behavior Game (GBG) is a universal classroom-based prevention program that has demonstrated long-lasting effects on preventing behavioral and emotional problems, substance use and improving educational attainment (Kellam, et al, 2008). While there has been substantial amount of studies conducted, most of them have been carried out in English-language environments. The purpose of this study was to test the newer version of the intervention (PAX Good Behavior Game) in Estonia and evaluate its impact on students’ mental health and behavior.

Methods: This was a pragmatic cluster-randomized waitlist-controlled trial conducted in 42 Estonian mainstream primary schools. Schools were matched to pairs and one school from each pair was randomly assigned to intervention or control group. 708 first grade students (7-8 years old) were followed up for 2 years and data was collected three times – at baseline (October 2016), first post-test (May 2017) and second post-test (May 2018). Primary outcome measure was Strengths and Difficulties Questionnaire (Goodman, 1999). Unmatched analysis was conducted as the matching correlation was not strong. Effects on students externalizing and internalizing behavior were analyzed using generalized estimating equation (GEE), adjusting for baseline score and child’s gender, and taking into account the clustering of students within schools.

Results: PAX GBG had a significant positive impact on students externalizing behavior (related to hyperactivity and conduct problems) rated by teachers: intervention group children demonstrated a decrease in scores by 2017 (B= -.67, 95% CI [-1.30, -.04], p=0.036) and by 2018 (B=-.86, 95% CI [-1.59, -.13], p=0.021). No statistically significant impact was measured on student’s internalizing behaviors rated by teachers, but the trending favored intervention in 2018 (B=-.67, p=0.052). Parents ratings did not show statistically significant differences compared to the control group.

Conclusions: This is the first experimental investigation of PAX GBG in Europe. It indicates that the intervention has positive effects on children’s externalizing behavior after adaptation to a new language and environment. Intervention effects did not transfer to home environment, which could indicate a need for an added parental component.