Effects of a school-based intervention on levels of anxiety and depression: a cluster-randomized controlled trial of the MindPower program in ten high schools in Norway.

BACKGROUND: The previous decades have shown increased symptoms of depression and anxiety among adolescents. To promote mental health and reduce mental illness, the government of Norway has, as in other countries, pledged that all schools must incorporate life-skills education. We report results from an evaluation of MindPower, a modification of the Coping With Depression (CWD) course, delivered universally in the classroom to secondary high school students, aged 15-16 years, in one county in Norway. The aim of the study was to evaluate the effect of MindPower on symptoms of depression and anxiety. METHODS: We utilized a two-groups` delayed intervention design where 110 first year high school classes were randomized into one of two intervention groups (IG1 and IG2). IG1 participated in MindPower while IG2 served as a control group for four months until the intervention started also in this group. IG1 and IG2 responded to questionnaires before and after the eight weeks course, at the start of the first and the second booster session, and at the five months follow up. Questionnaires, including online versions of the Hopkins Symptom Checklist (SCL-8) and the Reynolds Adolescent Depression Scale (RADS-2:SF), were administered to 1673 out of a total of 2384 students. SCL-levels were also compared with those from a large population study (UngData). RESULTS: According to mixed model analyses, SCL-8 and RADS-2:SF showed significant baseline differences between IG1 and IG2. In IG1 and IG2, both SCL-8 and RADS-2:SF showed a small but significant increase in mean scores throughout the study period, with markedly lower mean scores among boys. The SCL-levels were first lower for both girls and boys and then after the completion of MindPower the SCL-levels, equal to the SCL-levels in UngData. CONCLUSIONS: No effects of the intervention were found. This large universal school-based trial suffered from considerable drop-out of participants. Experiences from implementation and evaluation of universal mental health promotion and preventive school interventions are thoroughly discussed, including, preparation, resources, support, time, realistic expectations, teacher selection and training, implementation, research designs and more. Several empirically based, practical advices are presented. Clinical Trial registration 27/08/2018. Registration number NCT03647826.

Pandemic-Related Stress Symptoms Among Norwegian Parents of Adolescents in Grades 6 to 8.

We investigated pandemic-related stress symptoms during the first COVID-19 lockdown period in spring 2020 among parents of adolescents that were 11 to 13 years old in the study period. We also investigated whether parental stress symptoms were associated with family situation and family activities during lockdown. Altogether 147 couples reported about their own trauma-related stress symptoms following the outbreak of the pandemic. Among the respondents, 9.5% of the mothers and 10.2% of the fathers had scores over cutoff on the screener (IES-6) measuring stress symptoms, a non-significant gender difference. Scores on the screener were not associated with family contamination or lockdown consequences. Family activities during lockdown did not impact the pandemic stress symptom levels. Whereas, the experience of the COVID-19 pandemic pose a stressor to most people, it is unlikely to be a criterion A event for other than directly affected families.

Six- and Twelve-Month Follow-up Results of a Cluster Randomized Controlled Trial of a CBT-Based Group Course.

In the current study, we examined the durability of intervention gains over a 6- and 12-month follow-up period after the implementation of a CBT-based group intervention "Adolescent Coping with Depression Course" (ACDC) for adolescents with subclinical or mild-to-moderate depression. Data were collected from 228 youth, 133 of whom were allocated to the 14-week ACDC intervention and 95 to the usual care (UC) control condition. Analyses for the main outcome variable of depressive symptoms were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time on an intention-to-treat basis. Results revealed that the reduction in depressive symptoms achieved during the intervention phase continued across the follow-up period for both ACDC and UC (i.e., depressive symptoms showed a significantly decreasing trend in both groups in intervention and follow-up phases); however, no differential effects between conditions were found during the follow-up phase. The direct and indirect effects of the intervention on the other outcome variables' follow-up results were also presented. ISRCTN registry ISRCTN19700389. Registered 6 October 2015. https://doi.org/10.1186/ISRCTN19700389 . Full Protocol: https://doi.org/10.1186/s12888-016-0954-y.

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.

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.

Hot and Cool Self-Regulation, Academic Competence, and Maladjustment: Mediating and Differential Relations.

This study examined differential and mediating relations between hot and cool self-regulation (Mage  = 48.2 months; N = 1,155, 48% girls), first-grade (Mage  = 77.5 months) maladjustment (externalizing [EXT] and internalizing [INT] behavior), and first- and second-grade (Mage  = 89.5 months) academic competence (AC). Using teacher reported EXT, INT, and AC, partial support for the differential perspective was found in that only hot self-regulation was significantly related to EXT, whereas both hot and cool self-regulation was significantly related to AC. Moreover, hot self-regulation indirectly predicted second-grade AC through first-grade EXT, lending some support for the mediating perspective also. The findings contribute to an understanding of how self-regulation is related to academic and behavioral school adjustment.

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.

A meta-analysis of group Cognitive Behavioral Therapy (CBT) interventions for adolescents with depression.

The aim of this meta-analysis was to systematically examine the short- and long-term effects of group Cognitive Behavioral Therapy (CBT) for adolescent depression and to examine the role of various moderators of the reported effect sizes. A comprehensive literature search of relevant randomized-controlled trials identified 23 studies containing 49 post-intervention and 56 follow-up comparisons. Standardized mean differences (SMD) were calculated both for post-intervention and follow-up. A three-level random effects approach was used to model the dependent effect sizes. Group CBT was more efficacious than control conditions both at post-intervention (SMD = -0.28, 95% CI [-0.36, -0.19]) and at follow-up (SMD = -0.21, 95% CI [-0.30, -0.11]). Having an inactive control group was associated with a larger post-intervention effect size, while having a longer follow-up duration was associated with a smaller follow-up effect size. Even though the effect sizes are low, research suggests that group CBT is a significant treatment for adolescent depression.

The longitudinal association between internalizing symptoms and academic achievement among immigrant and non-immigrant children in Norway.

The aim of this study was to explore the longitudinal relation between internalizing symptoms and academic achievement, as two processes of children and youth development, among children in Norway, and whether having an immigrant background moderated this association. Data collected from 4,458 students in Norway in four waves over three years were analyzed with multi-group latent growth curve modeling (LGM). Results showed that internalizing symptoms level remained unchanged over time both for immigrant and non-immigrant children, while levels of academic achievement increased only for children of immigrants with both parents born outside of Norway. Further analyses supported a reciprocal relation between internalizing symptoms and academic achievement and revealed that the initial level of academic achievement predicted the rate of change in internalizing symptoms over time, but not vice versa. Moreover, immigrant background did not moderate the associations in the model, however, children of immigrants with both parents born abroad initially had lower levels of academic achievement, but showed an increase in academic achievement, compared to their non-immigrant peers as well as to peers with one native-born parent after controlling for gender and their grade at the first observation. The implications for policy and practice were discussed.

The Longitudinal Relation between Daily Hassles and Depressive Symptoms among Unaccompanied Refugees in Norway.

The aim of the present longitudinal study is to understand the longitudinal relation between depressive symptoms and daily hassles (i.e., general and acculturation hassles) in a high-risk population of unaccompanied refugees. We investigated the validity of three stress-mental health models: the stress exposure model, the stress generation model, and the reciprocal model. Data were collected from 918 unaccompanied refugees in Norway in three waves. Of the initial sample, the majority (82.1%) were male (M age = 19.01 years, SD = 2.54 years). The data were analyzed with auto-regressive cross-lagged modeling and latent growth curve modeling. The results supported the stress exposure model for the relation between depressive symptoms and acculturation hassles, indicating that acculturation hassles predicted the subsequent levels of depressive symptoms rather than vice versa. On the other hand, the reciprocal model was supported for the relation between depressive symptoms and general hassles indicating a bidirectional, mutual relation. Unconditional latent growth models further showed that depression level remained unchanged over time, while levels of acculturation and general hassles decreased. The implications for clinical practice and immigration policy are discussed.

Study protocol for a randomized controlled trial of a group cognitive-behavioral course for depressed adolescents.

BACKGROUND: School dropout is considered a serious problem in high schools in Norway. Despite studies which emphasize the importance of mental health as a unique risk factor for dropout, interventions have only taken this into account to a limited extent. Depression is one of the most prevalent mental health issues. Here we report the study protocol of a cluster randomized controlled trial of a group-CBT intervention, "Adolescent Coping with Depression Course" (ACDC) for depressed adolescents in upper secondary school. METHOD: The aim of this study is to investigate the extent to which ACDC can reduce depressive symptoms, prevent dropout and improve academic and social functioning among adolescents in upper secondary school. This study investigates the effectiveness of ACDC through a cluster randomized trial, in which course leaders are randomized to experimental or control conditions where the control groups receive usual care. DISCUSSION: The intervention is expected to reduce depressive symptoms among adolescents. The study will further investigate whether the intervention can prevent dropout and improve academic and social functioning among adolescents in upper secondary school. TRIAL REGISTRATION: ISRCTN registry ISRCTN19700389 . Registered 6 October 2015.

Depression among unaccompanied minor refugees: the relative contribution of general and acculturation-specific daily hassles.

OBJECTIVES: This study is designed to provide an empirical conceptualization of daily hassles among unaccompanied refugees, and whether they might affect mental health of young refugees after resettlement. First, we examined the underlying structure of daily hassles conceptualized as measuring general and acculturation-specific hassles. Second, we examined whether these two distinct categories of daily hassles significantly contribute to depression above and beyond the impact of premigration trauma. DESIGN: The study was based on self-report questionnaire data collected from 895 unaccompanied refugees who had been granted residence in Norway. RESULTS: Using structural equation modeling, the results confirmed the grouping of hassles in two general categories, which explained 43% of the variance in depression. CONCLUSION: The findings underscore the importance of current life conditions for unaccompanied refugees' mental health.

The role of social support in the acculturation and mental health of unaccompanied minor asylum seekers.

There is a lack of knowledge about psychosocial resources that may sustain post-resettlement psychological adjustment among unaccompanied minor asylum-seekers. The aim of this study is to investigate the impact of social support from family abroad and friends on acculturation, discrimination, and mental health among these vulnerable children and youth. Questionnaire data were collected from a population-based multi-ethnic sample involving 895 unaccompanied minors resettled in municipalities in all regions of the country. They met in groups in their local communities. The informants were on average 18.6 years, and had an average length of stay in Norway of 3.5 years. The findings showed that the participants suffered from high levels of ongoing war related intrusive symptoms and depression. Still, at the same time they engaged in adaptation processes that are normative to youth with immigrant backgrounds, in terms of constructing supportive networks and developing culture competence. In accordance with the main effect hypothesis, social support had direct effects on depression and indirect effects by increasing culture competence that may aid the young refugees in dealing with discrimination. However, there were no effects of social support on symptoms of PTSD. The findings give direction to areas of interventions, beyond dealing with the sequel of the traumas the unaccompanied minors have been exposed to, not only for clinicians, but also social workers and school personnel.

Perceived support from healthcare professionals, shock anxiety and post-traumatic stress in implantable cardioverter defibrillator recipients.

AIMS AND OBJECTIVES: To investigate (1) the extent to which shock anxiety and perceived support from healthcare professionals are related to post-traumatic stress disease (PTSD) symptoms and (2) the extent to which perceived support from healthcare professionals moderates the relationship between shock anxiety and PTSD symptoms in implantable cardioverter defibrillator recipients. An additional aim was to describe the level of PTSD symptoms and perceptions of support from healthcare professionals. BACKGROUND: Studies examining PTSD symptoms among implantable cardioverter defibrillator recipients are still sparse. In addition, little is known about how perceived support from healthcare professionals is related to PTSD symptoms. DESIGN: Cross-sectional survey design. METHODS: Recipients (n = 167) with implantable cardioverter defibrillator attending an outpatient device clinic completed questionnaires assessing shock anxiety, PTSD symptoms and perceived support from healthcare professionals. RESULTS: The results indicated that between ten and 15% of the recipients experienced moderate to severe symptoms of PTSD. Although a majority perceived constructive support from healthcare professionals, 12% perceived nonconstructive support. Regression analysis demonstrated that shock anxiety and perceived nonconstructive support from healthcare professionals had a statistically significant (p < 0·01) association with PTSD symptoms. Moreover, the results suggest that associations between shock anxiety and PTSD symptoms were significantly (p < 0·01) moderated by perceived nonconstructive support from healthcare professionals. Young age, short time since implantation and secondary prevention indication were also significantly associated with PTSD symptoms. CONCLUSIONS: The results indicate that nonconstructive support from healthcare professionals can increase the tendency to develop PTSD symptoms, particularly in those who experience shock anxiety. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals should pay more attention to the way in which they communicate information to the recipients during follow-up visits. Clinically based strategies and interventions targeting shock anxiety and PTSD symptoms should be carried out.

Problemas de Conducta y Depresión entre Refugiados no Acom-pañados: La asociación entre el impacto del trauma pre-migratorio y la aculturación / Conduct Problems and Depression among Unaccompanied Refugees: The Association with Pre-Migration Trauma and Acculturation

Hay escaso conocimiento sobre la adaptación a largo plazo de los niños menores de edad que emigran sin ser acompañados por sus padres para pedir asilo en un país extranjero. El presente estudio investigó los efectos combinados del impacto de haber tenido experiencias traumáticas relacionadas con la guerra antes de emigrar y los índices del proceso de aculturación actual (competencia cultural y problemas con endogrupos / exogrupos) sobre la depresión y los problemas conductuales. Los participantes fueron 566 refugiados menores no acompañados que habían llegado a Noruega buscando asilo y a los que se concedió la residencia y que estaban domiciliados por todo el país. Su estancia media en Noruega era de 3,7 años y su edad media era de 18,9 años. Se reunían en grupos en sus lugares de residencia y rellenaban cuestionarios con información acerca de sus experiencias pre y post- migratorias y de su salud mental. Los resultados encontrados indican que, aunque este grupo de jóvenes refugiados informa de pocos problemas de conducta, el nivel de depresión es alto. Sin embargo, a pesar de los problemas de depresión, su proceso de aculturación hace progresos, ya que están adquiriendo la competencia cultural necesaria para integrarse en la sociedad mayoritaria y mantener el contacto con su cultura de origen. Un modelo para evaluar los efectos de la competencia cultural y de los problemas con endogrupos/exogrupos en combinación con el impacto de experiencias traumáticas relacionadas con la guerra no explicaba gran parte de las diferencias individuales en los problemas de conducta. En cambio, los índices de aculturación explicaban una variación sustancial de los problemas de depresión, por encima de los efectos del impacto de experiencias traumáticas relacionadas con la guerra. Se concluye que la competencia cultural étnica y de la sociedad de acogida debe ser el enfoque a seguir en las intervenciones para impulsar la integración socio-cultural y la salud mental (AU)

There is scarce knowledge about the long term adaptation of children who migrate without the company of their legal guardians to apply for asylum in a foreign country. The present study investigated the combined effects of impact of premigratory war-related trauma, and indices of current acculturation (culture competence and ingroup / outgroup hassles) on conduct and depression problems. Participants were 566 refugees who had arrived in Norway as unaccompanied minor asylumseekers, were granted residence and resettled all over the country. They had a mean length of stay in Norway of 3.7 years and a mean age of 18.9 years. They gathered in groups in their home towns, and filled in questionnaires with information about pre- and post-migration experiences and mental health. The findings imply that while this group of young refugees reports few conduct problems, the level of depression is high. At the same time, their acculturation process is progressing, as they are achieving necessary culture competence to integrate into majority society and maintain contact with their culture of origin. A model assessing effects of culture competence and ingroup/outgroup hassles in combination with impact of war-related traumatic events, did not account for much of the individual differences in conduct problems. In contrast, when depressive problems were concerned, the included acculturation indices explained substantial variation in depression problems, over and above effects of impact of war-related traumatic events. It is concluded that ethnic and host culture competence should be the focus of interventions to promote socio-cultural integration and mental health (AU)

Bullying and PTSD symptoms.

PTSD symptoms related to school bullying have rarely been investigated, and never in national samples. We used data from a national survey to investigate this among students from grades 8 and 9 (n = 963). The prevalence estimates of exposure to bullying were within the range of earlier research findings. Multinomial logistic regression showed that boys were 2.27 times more likely to be exposed to frequent bullying than girls. A latent variable second-order model demonstrated an association between frequency of bullying exposure and PTSD symptoms (beta = 0.49). This relationship was not moderated by gender. However, the average levels of PTSD symptoms as well as clinical range symptoms were higher for girls. For all bullied students, 27.6% of the boys and 40.5% of the girls had scores within the clinical range. A mimic model showed that youth who identify as being both a bully and a victim of bullying were more troubled than those who were victims only. Our findings support the idea that exposure to bullying is a potential risk factor for PTSD symptoms among students. Future research could investigate whether the same holds for PTSD through diagnostic procedures, but this will depend on whether or not bullying is decided to comply with the DSM-IV classification of trauma required for diagnosis. Results are discussed with regard to their implications for school interventions.

School-based intervention programs for PTSD symptoms: a review and meta-analysis.

This is a review and meta-analysis of school-based intervention programs targeted at reducing symptoms of posttraumatic stress disorder (PTSD). Nineteen studies conducted in 9 different countries satisfied the inclusionary criteria. The studies dealt with various kinds of type I and type II trauma exposure. Sixteen studies used cognitive-behavioral therapy methods; the others used play/art, eye movement desensitization and reprocessing, and mind-body techniques. The overall effect size for the 19 studies was d = 0.68 (SD = 0.41), indicating a medium-large effect in relation to reducing symptoms of PTSD. The authors' findings suggest that intervention provided within the school setting can be effective in helping children and adolescents following traumatic events.

Antecedents and outcomes of intervention program participation and task priority change among school psychology counselors: a latent variable growth framework.

A three-year national intervention program introduced into the School Psychology Service (SPS) in Norway with the aim of increasing systemic level work among SP counselors was investigated. Latent variable growth models based on longitudinal data from 195 SP counselors gave no significant mean level change in systemic level work. This concurred with GLM analyses based on data from a sample of 20 schools. However, retrospective self-reported significant positive mean level change for systemic level work was detected among the SP counselors. Intervention program participation was associated with individual change in systemic level work. Self-efficacy beliefs about systemic level work, and school-related etiology beliefs predicted individual change to a certain degree. Comparison of two rival models gave no support for a hypothesized interaction among intervention program participation and beliefs in their effects on systemic level work. Open-ended questions indicated that individual level workload and the perceived expectations from the schools may have concern for a successful effect of the intervention program in addition to the hypothesized ones. Individual change in systemic level work was positively associated with individual change in job satisfaction.

Social psychological processes in family and school: more evidence on their relative etiological significance for bullying behavior.

This study looked at students' perceptions of the three socialization processes of connection, regulation, and autonomy with their parents and teachers, and the relation of these issues to bullying peers. Self-reported data were collected from a representative sample of Norwegian eighth graders (N=2,083, 1,010 boys, and 1,073 girls). Findings partially confirm our hypotheses that we generated from earlier research into general antisocial behavior. For both genders, parent regulation and teacher regulation had a direct impact on bullying behavior. Parent connection and teacher connection also had an impact on bullying behavior, but these effects were indirect and were mediated by regulation and autonomy from parents and teachers. Some of the socialization processes had different impacts on bullying behavior for boys and girls. Parent autonomy and teacher autonomy had impact (although weak) on bullying behavior for boys only. In general, the variables related to the parents were of more importance for bullying behavior than the variables related to the teachers.

Effects of a group-based counselling programme on diabetes-related stress, coping, psychological well-being and metabolic control in adults with type 1 or type 2 diabetes.

This study was designed to determine whether participation in a group-based counselling programme would result in reduced diabetes-related stress, improved coping and psychological well-being as well as achieving glycaemic control closer to an acceptable level. Effects of the programme were evaluated implementing an experimental design with a sample comprising 63 Norwegian adults with both types of diabetes aged between 25 and 70. At the 6-month follow-up, results indicate that the group-based counselling programme tested in the present study has the potential to reduce diabetes-related stress and self-blame as well as to improve coping in adults with diabetes. Moreover, results suggest that the programme can help participants to achieve more acceptable HbA1c levels as well. The present study indicates that this group-based counselling programme is feasible in the sense of suggesting that cognitive restructuring and problem-solving approaches in groups may be useful in helping people adjust to diabetes.