Study Protocol: How Does School Affect Adolescent Mental Health?

The Kupol study provides a unique platform to evaluate the association between different aspects of school and adolescent mental health.

Researchers in Sweden are conducting a prospective cohort study to examine the association between teaching practices and social environments in schools and the risk of adolescent mental health problems and psychiatric disorders. The study protocol was published in BMC Psychiatry.

“Longitudinal studies indicate strong associations between school proficiency and indicators of mental health throughout adulthood, but the mechanisms of such associations are not fully elucidated,” wrote Maria Rosaria Galanti, MD, PhD, from the Department of Public Health Sciences in the Centre for Epidemiology and Community Medicine (CES) at the Karolinska Institutet in Stockholm County’s Health Care District (SLSO) and colleagues.

The authors explained that the influence of teaching and social environments on adolescent mental health is insufficiently investigated, particularly in Sweden. “Because of the multiple pathways involved, a singular focus is sometimes placed on what children bring with them when they enter schools (eg, children’s social background) rather than on school environment or the complex interaction between multiple influences,” the authors wrote.

The researchers are conducting the Kupol study (an acronym for “Knowledge on young people’s mental health and learning” in Swedish), a prospective cohort study to investigate changes in adolescents’ mental health in relation to changes in school.

Specifically, the study aims: (a) to evaluate how teaching methods, teaching leadership, and teacher-student relations in school might affect the risk of mental health issues and psychiatric disorders in adolescence, (b) to evaluate the direct effects of teaching and environment in schools on mental health as well as the effects mediated by students’ individual academic achievements, and (c) to assess if school is associated with mental health issues by studying genes that regulate stress response.

The researchers recruited seventh graders from the school years of 2013-2014 and 2014-2015 in both urban and rural areas of 8 regions of southern and central Sweden: Gävleborg, Jönköping, Stockholm, Södermanland, Uppsala, Värmland, Västmanland, and Örebro. Of the 535 eligible schools, 101 (19 %) were willing to participate in the study. Out of 3959 children who agreed to participate, 3671 children (48.2% boys) provided responses to baseline (92.7%). Parents were also invited to participate. The majority of the participants had highly educated parents.

Two follow up surveys were conducted during the years when the children were still in compulsory school, with a third planned during the transition to upper secondary school (2017-2019).

Perceptions of the school’s culture, reputation, and social climate is being collected from children and teachers using the PESOC scale (Pedagogical and Social Climate of a school). Mental health is being assessed with the 25-item Strengths and Difficulties Questionnaire (SDQ) completed by both children and their parents. The Center for Epidemiologic Studies Depression Scale for Children (CES-DC) is also being used. At baseline, 5% of the scores from the SDQ and 9.6% of the scores from the CES-DS indicated mental health problems.

Saliva samples will also be collected from about 1500 students at baseline and at the end of 9th grade. Each occasion will include 3 samples, one to test morning cortisol levels, one to test afternoon cortisol levels, and one for genetic and epigenetic analyses.

Further information about class, family, and child characteristics was collected at baseline and at follow-up to gain insight into potential confounding factors.

“The main strengths of the Kupol study include its longitudinal design, with yearly data collection during and beyond upper primary school, and the wide range of information available on different levels, using multiinformant and multi-method assessments. A rich data set is being compiled through the use of registers, surveys at the school, classroom, student and parent level, as well as through collection of biological samples,” the authors wrote. “In summary, the Kupol study cohort provides a unique platform to evaluate the association between different dimensions of school level factors and mental health among adolescents.”


Galanti MR, Hultin H, Dalman C, et al. School environment and mental health in early adolescence – a longitudinal study in Sweden (KUPOL). BMC Psychiatry. 2016;16(243). doi:10.1186/s12888-016-0919-1.

More information at the study’s website.

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