Implementation and effectiveness of a school-based intervention to increase adherence to national school meal guidelines: a non-randomised controlled trial.

OBJECTIVE: Implementation of school meal guidelines is often inadequate, and evidence for effective implementation strategies for school-based nutrition interventions is limited. The aim of the present study was to examine the implementation and effectiveness of a multi-strategy implementation intervention to increase adherence to the Norwegian national school meal guideline. DESIGN: The study was a school-based hybrid implementation effectiveness trial with a pre-post non-equivalent control group design, testing three implementation strategies: internal facilitation, training and an educational meeting. SETTING: Primary schools and after-school services in two counties in south-east Norway. PARTICIPANTS: School principals, after-school leaders and class teachers from thirty-three schools in the intervention county and principals and after-school leaders from thirty-four schools in a comparison county. RESULTS: There was a significant difference of 4 percentage points in change scores between the intervention and the comparison groups at follow-up, after adjusting for baseline adherence (B = 0·04, seB = 0·01, t = 3·10, P = 0·003). The intervention effect was not associated with the school's socio-economic profile. School-level fidelity was the implementation dimension that was most strongly correlated (r s = 0·48) with the change scores in the intervention group, indicating that principals' support is important for gaining the largest intervention effects. CONCLUSIONS: A school-based intervention with low intensity, based on trained teachers as internal facilitators, can increase adherence to the national school meal guideline among Norwegian primary schools, irrespective of local socio-economic conditions. Implementation fidelity, at an organisational level, may be a useful predictor for intervention outcomes in schools.

Knowledge and Will: An Explorative Study on the Implementation of School-Wide Positive Behavior Support in Sweden.

School-wide positive behavior support (SWPBIS) is a well-evaluated school approach to promoting a positive school climate and decreasing problem behaviors. Initial implementation is one of the most critical stages of program implementation. In this qualitative study, the initial implementation of SWPBIS in Swedish schools was studied using an implementation model of behavior change as guidance for interviews and analyses. The study makes significant contributions to previous research as little is known of the implementation of SWPBIS in Swedish context. Focus-group interviews were conducted with 59 professionals on implementation teams from nine schools. Themes were extracted according to implementation team members' perceptions and descriptions of how the initial implementation was carried out. The results of this study revealed relevant themes within the three domains of Capability, Opportunity, and Motivation. Core features were found under the themes of knowledge and experience of similar evidence-based programs, process or result orientation, time, manual content, organizational prerequisites, team functioning, implementation leadership, program as a unifying factor, program aligning with staff beliefs, plausible expectations, and emotional reinforcement. Results are discussed in terms of how they can be used in continuing to develop the Swedish model of SWPBIS. Implications regarding implementation in Swedish schools are discussed, as is the applicability of the model of behavior change for studying implementation in schools.

Bullying Victimization and Trauma.

Bullying victimization and trauma research traditions operate quite separately. Hence, it is unclear from the literature whether bullying victimization should be considered as a form of interpersonal trauma. We review studies that connect bullying victimization with symptoms of PTSD, and in doing so, demonstrate that a conceptual understanding of the consequences of childhood bullying needs to be framed within a developmental perspective. We discuss two potential diagnoses that ought to be considered in the context of bullying victimization: (1) developmental trauma disorder, which was suggested but not accepted as a new diagnosis in the DSM-5 and (2) complex post-traumatic stress disorder, which has been included in the ICD-11. Our conclusion is that these frameworks capture the complexity of the symptoms associated with bullying victimization better than PTSD. We encourage practitioners to understand how exposure to bullying interacts with development at different ages when addressing the consequences for targets and when designing interventions that account for the duration, intensity, and sequelae of this type of interpersonal trauma.

Impacts of school-wide positive behaviour support: Results from National Longitudinal Register Data.

Problem behaviour in schools may have detrimental effects both on students' well-being and academic achievement. A large literature has consistently found that school-wide positive behaviour support (SWPBS) successfully addresses social and behavioural problems. In this paper, we used population-wide longitudinal register data for all Norwegian primary schools and a difference-in-difference (DiD) design to evaluate effects of SWPBS on a number of primary and secondary outcomes, including indicators of externalising behaviour, school well-being, pull-out instruction, and academic achievement. Indications of reduced classroom noise were found. No other effects were detected. Analyses revealed important differences in outcomes between the intervention and control schools, independent of the implementation of SWPBS, and that a credible design like DiD is essential to handle such school differences.

Predictors of family focused practice: organisation, profession, or the role as child responsible personnel?

BACKGROUND: Health professionals in Norway are required by law to help safeguard information and follow-up with children of parents with mental or physical illness, or who have substance abuse problems, to reduce their higher risk of psychosocial problems. Knowledge is lacking regarding whether organisation and/or worker-related factors can explain the differences in health professionals' ability to support the families when patients are parents. METHODS: Employing a translated, generic version of the Family Focused Mental Health Practice Questionnaire (FFPQ), this cross-sectional study examines family focused practice (FFP) differences in relation to health professionals' background and role (N = 280) along with exploring predictors of parent, child, and family support. RESULTS: While most health professions had begun to have conversations with parents on children's needs, under one-third have had conversations with children. There were significant differences between nurses, social workers, psychologists, physicians, and others on seven of the FFP subscales, with physicians scoring lowest on five subscales and psychologists providing the least family support. Controlling for confounders, there were significant differences between child responsible personnel (CRP) and other clinicians (C), with CRP scoring significantly higher on knowledge and skills, confidence, and referrals. Predictors of FFP varied between less complex practices (talking with parents) and more complex practices (family support and referrals). CONCLUSION: The type of profession was a key predictor of delivering family support, suggesting that social workers have more undergraduate training to support families, followed by nurses; alternately, the results could suggest that that social workers and nurses have been more willing or able than physicians and psychologists to follow the new legal requirements. The findings highlight the importance of multidisciplinary teams and of tailoring training strategies to health professionals' needs in order to strengthen their ability to better support children and families when a parent is ill.

The relation between behavioral problems and social competence: A correlational Meta-analysis.

BACKGROUND: Previous studies have shown that children who display behavioral problems also tend to display low social competence. The relation does however vary according to type of behavior being measured, as well as demographic characteristics of the respondent. The present meta-analysis examined the correlation between different types of behavioral problems and social competence among children aged 3-13, and investigated possible moderators in this relation. METHODS: A systematic literature search was conducted for English language studies from January 2008 to January 2018 that reported correlations between three types of behavioral problems (i.e., externalizing behaviors, conduct problems, or aggression) and two types of social competence (i.e., social competence or social skills). The studies included reports from parents and teachers, or both as a dyad. The review included data from 54 independent studies and a total of 46,828 participants. Effect sizes were estimated using a random effects approach and moderator analyses between subsets of categorical variables were tested by the significant Q test. RESULTS: Results showed an overall correlation between behavioral problems and social competence of medium effect size (r = -.42, p < .01). Moderation analyses indicated no significant differences for different types of behavioral problems or social competence. However, a significant difference was found with regard to type of respondent; the correlation was significantly higher when both measures were reported by the same respondent (teacher or parent) compared to when measures were reported by parent-teacher as a dyad. CONCLUSIONS: Findings summarized and quantified a robust negative correlation between behavioral problems and social competence. The results indicate that intervention programs targeting problem behaviors in children would benefit from reducing behavioral problems and in concert, increase social competence to help children with emerging or present problem behaviors.

Significance of Leaders for Sustained Use of Evidence-Based Practices: A Qualitative Focus-Group Study with Mental Health Practitioners.

Evidence-based practices that are implemented in mental health services are often challenging to sustain. In this focus-group study, 26 mental health practitioners with high fidelity scores were interviewed regarding their experiences with implementing the illness management and recovery, an evidence-based practice for people with severe mental disorders, in their services and how this could influence further use. Findings indicate that high fidelity is not equivalent to successful implementation. Rather, to sustain the practice in services, the practitioners emphasized the importance of their leaders being positive and engaged in the intervention, and hold clear goals and visions for the intervention in the clinic. In addition, the practitioners' understanding of outcome monitoring as a resource for practice improvement must be improved to avoid random patient experiences becoming the decisive factor in determining further use.Trial registration: ClinicalTrials.gov NCT02077829. Registered 25 February 2014.

Cognitive behavioral treatment for depressed adolescents: results from a cluster randomized controlled trial of a group course.

BACKGROUND: The group-based CBT intervention, the Adolescent Coping with Depression Course (ACDC), has previously been evaluated within a quasi-experimental design, showing reduction in depressive symptoms compared to a benchmark of similar studies. The aim of our study was to investigate the effectiveness of ACDC within a randomized controlled (RCT) design. METHOD: Thirty-five course/control leaders randomly assigned to provide ACDC or usual care (UC) recruited 133 adolescents allocated to ACDC and 95 to UC. ACDC participants received eight weekly sessions and two follow-up sessions about 3 and 6 weeks after the last session. UC participants received usual care as implemented at the different sites. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale for adolescents (CES-D), perfectionism with the revised version of the Dysfunctional Attitude Scale (DAS), and rumination with the revised version of the Ruminative Responses Scale (RRS). Attrition was considered missing at random (MAR) and handled with a full information maximum likelihood (FIML) procedure. RESULTS: Intention to treat analysis (ITT), including baseline scores and predictors of missing data as control or auxiliary variables, showed a small to medium reduction in depressive symptoms for the ACDC group compared to UC (d = -.31). Changes in perfectionism and rumination in favor of the intervention were also significant. Sensitivity analyses confirmed the findings from the ITT analyses. CONCLUSIONS: The current study supports the effectiveness of this group-based CBT intervention. The intervention can hopefully result in clinically significant reductions in symptoms associated with depression among adolescents. TRIAL REGISTRATION: ISRCTN registry ISRCTN19700389 . Registered 6 October 2015.

Awareness and perceptions of clinical guidelines for the diagnostics and treatment of severe behavioural problems in children across Europe: A qualitative survey with academic experts.

BACKGROUND: Severe behavioural problems (SBPs1) in childhood are highly prevalent, impair functioning, and predict negative outcomes later in life. Over the last decade, clinical practice guidelines for SBPs have been developed across Europe to facilitate the translation of scientific evidence into clinical practice. This study outlines the results of an investigation into academic experts' perspectives on the current prevalence, implementation, and utility of clinical guidelines for SBPs in children aged 6-12 across Europe. METHODS: An online semi-structured questionnaire was completed by 28 psychiatry and psychology experts from 23 countries. RESULTS: Experts indicated that approximately two thirds of the included European countries use at least an unofficial clinical document such as textbooks, while nearly half possess official guidelines for SBPs. Experts believed that, although useful for practice, guidelines' benefits would be maximised if they included more specific recommendations and were implemented more conscientiously. Similarly, experts suggested that unofficial clinical documents offer a wide range of treatment options to individualise treatment from. However, they stressed the need for more consistent, evidence-based clinical practices, by means of developing national and European clinical guidelines for SBPs. CONCLUSIONS: This study offers a preliminary insight into the current successes and challenges perceived by experts around Europe associated with guidelines and documents for SBPs, acting as a stepping stone for future systematic, in-depth investigations of guidelines. Additionally, it establishes experts' consensus for the need to develop official guidelines better tailored to clinical practice, creating a momentum for a transition towards European clinical guidelines for this population.

General and specific factors of working alliance in parent training: A bifactor exploratory structural equation modelling approach.

The Working Alliance Inventory Short form (WAI-S) comprises 12 items that measure 3 subdomains (goal, task, and bond). In the present study, we evaluated the factor structure of WAI-S in a parent management training (PMT) context, by investigating a series of different factor models, including standard confirmatory factor analyses (CFA) models and more recent alternatives, like the exploratory structural equation model (ESEM), the bifactor-CFA, and the bifactor exploratory structural equation model (B-ESEM). The study sample consisted of 259 Norwegian parents receiving PMT - the Oregon model (PMTO). Alliance was rated by parents of children with emerging or present conduct problems after the first therapy session. Results showed that the B-ESEM model provided best model fit to the data. Estimated sources of variance and omega reliabilities supported a strong general alliance factor, but revealed poor quality of the specific factors. Overall, the present study implies that specific factors of working alliance should be interpreted with caution; rather one should rely on a general working alliance construct. Clinical or methodological significance of this article: Findings suggest that working alliance, as measured by WAI-S in a PMT context, is best reflected by a general construct that also take into account multidimensionality. However, only the general factors provide acceptable reliability. Consequently, practitioners should use the specific factors with caution. The indicators of the specific factors should be improved.

Differences in implementation of family focused practice in hospitals: a cross-sectional study.

BACKGROUND: Changes in Norwegian law and health policy require all health professionals to help safeguard the provision of information and follow-up for the children of parents with mental or physical illness, or substance abuse problems, to decrease their risk of psychosocial problems. There is a lack of knowledge on how the national changes have been received by hospital-based health professionals, and if they have led to an increase in family focused practice. METHODS: This cross-sectional study examined the adherence of health professionals' (N = 280) in five hospitals to new guidelines for family focused practice, using a translated and generic version of Family Focused Mental Health Practice Questionnaire. RESULTS: Overall, health professionals scored high on knowledge and skills, and were confident in working with families and children, but reported moderate levels of family support and referrals. Comparison of the five hospitals showed significant differences in terms of workplace support, knowledge and skills and family support. The smallest hospital had less workplace support and less knowledge and skills but scored medium on family support. The two largest hospitals scored highest on family support, but with significant differences on parents refusing to have conversations with children. CONCLUSIONS: Differences in implementation of family focused practice highlight the need to tailor improvement strategies to specific barriers at the different hospitals. The use of implementation theories and improvement strategies could promote full implementation, where all families and children in need were identified and had access to family support.Trial registration The study is approved by the Regional Committee on Medical and Health Research Ethics South-East Q5 37 (reg. no. 2012/1176) and by the Privacy Ombudsman.

Behavioral Trajectories During Middle Childhood: Differential Effects of the School-Wide Positive Behavior Support Model.

The aims of this study were to assess the longitudinal trajectories of externalizing problem behavior during middle childhood among typically developing children and to examine subgroup differences in the effectiveness of the School-Wide Positive Behavior Support (SWPBS) model, called N-PALS in Norway. Participants were approximately 3000 students, and behavioral assessments were performed by class head teachers at four time points from the 4th or 5th grade through the 7th grade. Using a combination of latent class growth analyses (LCGA) and growth mixture modeling (GMM), four distinct trajectory classes were identified, i.e., persistent low (84.4%), persistent high (2.5%), decreasing (7.9%), and increasing (5.3%). An indication of a significant positive effect of the N-PALS model was found for students with a persistently high-risk trajectory. The current study adds to the evidence that this school-wide prevention model can moderate the development of externalizing behavior problems among children and youth.

Hospitals implementing changes in law to protect children of ill parents: a cross-sectional study.

BACKGROUND: Norway is one of the first countries to require all health professionals to play a part in prevention for children of parents with all kinds of illnesses (mental illness, drug addiction, or severe physical illness or injury) in order to mitigate their increased risk of psychosocial problems. Hospitals are required to have child responsible personnel (CRP) to promote and coordinate support given by health professionals to patients who are parents and to their children. METHODS: This study examined the extent to which the new law had been implemented as intended in Norwegian hospitals, using Fixsen's Active Implementation Framework. A stratified random sample of managers and child responsible personnel (n = 167) from five Hospitals filled in an adapted version of the Implementation Components Questionnaire (ICQ) about the implementation of policy changes. Additional information was collected from 21 hospital coordinators (H-CRP) from 16 other hospitals. RESULTS: Significant differences were found between the five hospitals, with lowest score from the smallest hopitals. Additional analysis, comparing the 21 hospitals, as reported by the H-CRP, suggests a clear pattern of smaller hospitals having less innovative resources to implement the policy changes. Leadership, resources and system intervention (strategies to work with other systems) were key predictors of a more successful implementation process. CONCLUSIONS: Legal changes are helpful, but quality improvements are needed to secure equal chances of protection and support for children of ill parents. TRIAL REGISTRATION: The study is approved by the Regional Committee on Medical and Health Research Etics South-East (reg.no. 2012/1176 ) and by the Privacy Ombudsmann.

Dimensionality of oppositional defiant disorder.

BACKGROUND: The present study examined dimensionality of oppositional defiant disorder (ODD) using 10 alternative items using network analysis and confirmatory factor analysis. METHODS: The sample constituted 551 Norwegian children aged 2-12 and their parents. We used network analysis to investigate the connections between different symptoms. Next, we analysed data using traditional confirmatory factor methods, including the more recently proposed bifactor approach. RESULTS: The bifactor model, with a strong general factor and three specific factors, provided the best model fit. Omega values did, however, reveal that only the general and the specific hurtful factor had satisfactory reliability. Network analysis showed that symptoms in general were positively connected within the ODD network. Strong connections between several symptoms within the irritable and hurtful cluster emerged, whereas some symptoms of the headstrong cluster seem to function as bridge nodes between the irritable and hurtful symptom clusters. CONCLUSIONS: The findings support a bifactor model of ODD indicators, but omegas only gave support to the use of a general latent factor, and one specific factor. Network analysis did, however, provide some additional and interesting findings, revealing clusters of strongly connected symptoms and central bridge node symptoms. Implications of the results are discussed.

How to implement Illness Management and Recovery (IMR) in mental health service settings: evaluation of the implementation strategy.

BACKGROUND: The purpose of this study was to evaluate the implementation strategy used in the first-phase of implementation of the Illness Management and Recovery (IMR) programme, an intervention for adults with severe mental illnesses, in nine mental health service settings in Norway. METHODS: A total of 9 clinical leaders, 31 clinicians, and 44 consumers at 9 service settings participated in the implementation of IMR. Implementation was conducted by an external team of researchers and an experienced trainer. Data were gathered on fidelity to the intervention and implementation strategy, feasibility, and consumer outcomes. RESULTS: Although the majority of clinicians scored within the acceptable range of high intervention fidelity, their participation in the implementation strategy appeared to moderate anticipated future use of IMR. No service settings reached high intervention fidelity scores for organizational quality improvement after 12 months of implementation. IMR implementation seemed feasible, albeit with some challenges. Consumer outcomes indicated significant improvements in illness self-management, severity of problems, functioning, and hope. There were nonsignificant positive changes in symptoms and quality of life. CONCLUSIONS: The implementation strategy appeared adequate to build clinician competence over time, enabling clinicians to provide treatment that increased functioning and hope for consumers. Additional efficient strategies should be incorporated to facilitate organizational change and thus secure the sustainability of the implemented practice. Trial registration ClinicalTrials.gov NCT02077829. Registered 25 February 2014.

Predictors of changes in child behaviour following parent management training: Child, context, and therapy factors.

This non-randomised study examined a set of predictive factors of changes in child behaviour following parent management training (PMTO). Families of 331 Norwegian girls (26%) and boys with clinic-level conduct problems participated. The children ranged in age from 3 to 12 years (Mage = 8.69). Retention rate was 72.2% at post-assessment. Child-, parent- and therapy-level variables were entered as predictors of multi-informant reported change in externalising behaviour and social skills. Behavioural improvements following PMTO amounted to 1 standard deviation on parent rated and ½ standard deviation on teacher rated externalising behaviour, while social skills improvements were more modest. Results suggested that children with higher symptom scores and lower social skills score at pre-treatment were more likely to show improvements in these areas. According to both parent- and teacher-ratings, girls tended to show greater improvements in externalising behaviour and social skills following treatment and, according to parents, ADHD symptomology appeared to inhibit improvements in social skills. Finally, observed increases in parental skill encouragement, therapists' satisfaction with treatment and the number of hours spent in therapy by children were also positive and significant predictors of child outcomes.

Is There a Scale-up Penalty? Testing Behavioral Change in the Scaling up of Parent Management Training in Norway.

In the present study, the scaling up of Parent Management Training, Oregon Model (PMTO) in Norway was examined by investigating how large-scale dissemination affected the composition of the target group and the service providers by comparing child behavioral outcomes in the effectiveness and dissemination phases of implementation. Despite the larger heterogeneity of the service providers and the intake characteristics of the target group, which are contrary to the expectations that were derived from the literature, no attenuation of program effects was detected when scaling up PMTO. In Norway, a long-term-funded centralized center, combined with an active implementation strategy, seems to have affected the quality of PMTO delivered system-wide in services for children with behavior problems.

Psychometric properties of the Norwegian version of the Evidence-Based Practice Attitude Scale (EBPAS): to measure implementation readiness.

BACKGROUND: Attitudes can be a precursor to the decision of whether or not to try a new practice. In order to tailor the implementation of evidence-based practices (EBPs) in mental health settings, we must first consider practitioner attitudes towards EBP adoption. To assess these attitudes, the Evidence-Based Practice Attitude Scale (EBPAS) was developed. The purpose of this study was to investigate the psychometric properties of the Norwegian version of the EBPAS, and to examine differences in attitudes towards implementing EBPs among mental health practitioners. METHODS: The EBPAS was translated into Norwegian and administered to 294 practitioners from seven primary and 22 specialized mental care units within a defined geographical area of Norway. RESULTS: The EBPAS showed good psychometric properties. The less clinical experience the practitioner had, the more positive their attitude toward EBPs. Primary care practitioners reported more positive attitudes towards implementing EBPs that were required of them than specialized care practitioners. CONCLUSIONS: The Norwegian version of the EBPAS is a promising tool for measuring implementation readiness in mental health services, and can be used in clinical practice to tailor implementation efforts. TRIAL REGISTRATION: The study was approved by the regional committees for medical and health research ethics [ REK 2013/2035 ] on 25(th) of May, 2014.

The short Working Alliance Inventory in parent training: Factor structure and longitudinal invariance.

OBJECTIVE: The purposes of the present study were twofold: (a) to examine the factor structure of the Working Alliance Inventory, Short (WAI-S) and (b) to investigate if factor loadings and thresholds fulfilled properties of longitudinal measurement invariance across two waves of data. METHOD: The study sample consisted of 259 Norwegian parents receiving Parent Management Training, the Oregon model. Parents rated alliance at sessions 3 and 12 during the therapy. Confirmatory factor analyses to assess the fit of a one-, two-, and three-factor model were performed using robust weighted least squares estimation for categorical indicators. RESULTS: The results showed that data provided best fit for the three-factor solution with goal, task, and bond. Furthermore, results demonstrated satisfactory invariance for factor loadings and thresholds across time. CONCLUSIONS: Overall, the results indicate that the WAI-S three-factor solution has acceptable psychometric properties for longitudinal measurement comparisons.

Children With Conduct Problems and Co-occurring ADHD: Behavioral Improvements Following Parent Management Training.

To scale up evidence-based treatment of conduct problems, parent management training, Oregon model (PMTO) has been disseminated throughout Norway. This study examined whether Attention Deficit Hyperactivity Disorder (ADHD) predicted the outcomes of PMTO. Of 253 children and families, 97 were reported to have an ADHD diagnosis. Although different at intake, the groups with and without ADHD had close to an equal change in behavioral status following treatment. Maternal depression and family income predicted the combined group's behavior following PMTO. The study indicates that reductions in conduct problems following PMTO are of the same magnitude in children with or without ADHD. However, some characteristics may differentially predict outcomes for children with combined problems.