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Effectiveness of a Universal, Classroom-Based Preventive Intervention (PAX GBG) in Estonia: a Cluster-Randomized Controlled Trial


The PAX Good Behavior Game (PAX GBG) is a behavior management strategy that has demonstrated positive effects on children’s behavior and well-being in trials conducted mainly in the USA. This study assessed the impact of the PAX GBG on students’ mental health and behavior 7 and 19 months post-baseline in Estonia. This matched-pair, cluster-randomized, waitlist-controlled, open-label trial included 42 Estonian elementary schools with 708 first-grade students. The primary outcome was children’s overall mental health rated by teachers, while secondary objectives were to examine whether the effects of the intervention extended to the home context. Teachers also rated their self-efficacy and overall classroom behavior. Intervention adherence and children’s exposure to the intervention were also measured. Modified intention to treat analysis involved 696 students on first post-baseline and 647 on second post-baseline. Intervention had positive effects on children’s mental health at the end of the first academic year, which lasted and strengthened during the second academic year. Moderation analysis demonstrated positive effects on mental health and prosocial behavior for high-risk students during the first year. A few positive effects extended to the home environment during the second academic year. Implementation fidelity was satisfactory. The intervention also had a positive lasting effect on teacher’s self-efficacy and overall classroom behavior. This study shows the positive effects of the PAX GBG in Estonian schools and supports broader implementation of the intervention in Estonian elementary schools.

Trial registration No. NCT02865603

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The authors would like to express their gratitude to the following people and institutions: PAXIS Institute and Dr. Dennis Embry; ERSI with prof. Merike Sisask and Joosep Vaikma; NIHD with Tiia Pertel, Anita Baumbach, Mari Orusalu, Kaja-Kristen Sune and Kai Klandorf.


The study was funded by the European Social Fund and Ministry of the Interior in Estonia.

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Correspondence to Karin Streimann.

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Ethical Approval

Ethical approval for the study was received from Tallinn Medical Research Ethics Committee on June 2016. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Streimann, K., Selart, A. & Trummal, A. Effectiveness of a Universal, Classroom-Based Preventive Intervention (PAX GBG) in Estonia: a Cluster-Randomized Controlled Trial. Prev Sci 21, 234–244 (2020).

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  • Universal prevention
  • Mental health
  • Good behavior game
  • Children
  • School