Johan Ahlen

Internet-delivered cognitive behavior therapy for children and adolescents : A systematic review and meta-analysis

Internet-delivered cognitive behavior therapy (ICBT) is a relatively novel treatment format with the potential to increase accessibility of evidence-based care. However, little is known about the feasibility and efficacy of ICBT in children and adolescents. We conducted a comprehensive systematic review and meta-analysis of ICBT for children and adolescents to provide an overview of the field and assess the efficacy of these interventions. A systematic literature search of six electronic databases was performed to identify ICBT intervention studies for children with a psychiatric condition, such as social anxiety disorder, or a somatic condition, such as chronic pain. Two reviewers independently rated study quality. Twenty-five studies, targeting 11 different disorders, were included in the review. Study quality and presentation of treatment variables, such as therapist time and treatment adherence, varied largely. Twenty-four studies (N=1882) were included in the meta-analysis and ICBT yielded moderate between-group effect sizes when compared with waitlist, g=0.62, 95% CI [0.41, 0.84]. The results suggest that CBT for psychiatric and somatic conditions in children and adolescents can be successfully adapted to an internet-delivered format.

School-based prevention of anxiety and depression: a pilot study in Sweden

Anxiety disorders are the most prevalent form of psychopathology in children. Anxiety disorders often begin early in life, involve great suffering, and predict psychiatric problems. Unfortunately, only a few children with anxiety disorders will receive effective treatment. The purpose of this study was to examine the effectiveness of FRIENDS for Life, an Australian school-based prevention programme, with children from Sweden. Participants were 50 children, and the impact of the programme was measured at three time points on the outcomes of anxiety, depression, and general mental health. Results showed a decrease in depressive symptoms and difficulties, and an increase in strengths, for those children receiving the programme. For those children at risk for anxiety receiving the programme, the results also showed a decrease in anxiety symptoms. Overall, the study suggests that FRIENDS for Life could be a promising intervention for Swedish children.

Prevention of Anxiety and Depression in Swedish School Children: a Cluster-Randomized Effectiveness Study

Our study aimed at evaluating FRIENDS for Life, an intervention to prevent anxiety and depression in Swedish school children. A total of 695 children between the ages of 8 and 11 were recruited from 17 schools in Stockholm, Sweden, and cluster-randomized to either the intervention or control group. Teachers in the intervention group received a full day of training and administered FRIENDS for Life in their classrooms. We assessed the children’s anxiety and depressive symptoms, general mental health, and academic performance at pre- and post-intervention as well as at the 12-month follow-up. A multi-informant approach was used with data collected from children, parents, and teachers. Assessment was done with the Spence Children’s Anxiety Scale, Children’s Depression Inventory, and the Strengths and Difficulties Questionnaire. Children’s baseline symptoms, gender, and age as well as their teacher’s use of supervision were examined as moderators of effect. Our study found no short- or long-term effects of the intervention for any outcome with regard to the entire sample. We found an enhanced effect of the intervention regarding children with elevated depressive symptoms at baseline. We found a decrease in anxiety symptoms among children whose teachers attended a larger number of supervision sessions, compared to children whose teachers attended fewer supervised sessions or the control group. Mediation analyses showed that this effect was driven by change in the last phase of the intervention, suggesting that supervision might play an important role in enhancing teachers’ ability to administer the intervention effectively.

Evaluation of the Children’s Depression Inventory—Short Version (CDI–S).

The Children’s Depression Inventory—Short Version (CDI–S), an abbreviated version of the widely used Children’s Depression Inventory (CDI), has been regularly used in recent research. In comparison to the original CDI, the CDI–S has not been rigorously evaluated for its psychometrics. The present study examined the dimensionality, convergent and discriminant validity, and gender differences of the CDI–S in a school-based sample of 809 children 8–12 years of age. All children completed the CDI–S. One subsample additionally completed another measure of depression, 1 subsample completed a measure of anxiety, and 1 subsample completed the CDI–S at a second occasion, after 2 weeks. Information regarding parents’ education and household income were available for 476 children. We evaluated the dimensionality of the CDI–S in a series of exploratory factor analyses. Despite some evidence of multidimensionality, a bifactor model revealed that the variation of scores was primarily explained by variations of the general factor. Consequently, the CDI–S is most adequately interpreted as a univocal measure. The CDI–S showed high correlation to another measure of depression and a moderately high correlation to a measure of anxiety, with nonoverlapping confidence intervals. We also found that girls reported higher levels of depressive symptoms than did boys, and we found a negative correlation between depressive symptoms and socioeconomic factors for boys only. Future studies should preferably include a broader age range, to acquire a more comprehensive understanding of the validity of the CDI–S.

Development of the Spence Children’s Anxiety Scale - Short Version (SCAS-S)

The literature provides several examples of anxiety symptoms questionnaires for children. However, these questionnaires generally contain many items, and might not be ideal for screening in large populations, or repeated testing in clinical settings. The Spence Children’s Anxiety Scale (SCAS) is an extensively used and evaluated 44-item questionnaire developed to assess anxiety symptoms in children, and provides a sound base for the development of an abbreviated anxiety symptoms questionnaire. Although methodological standards have been presented in how to develop abbreviated questionnaires, previous studies have often suffered from several limitations regarding validating procedures. Guided by these methodological standards, the current study aimed at developing an abbreviated version of the SCAS, while retaining the content, convergent, and divergent validity of the original scale. A school-based sample (n = 750) was used to reduce the number of items, and an independent school-based sample (n = 371) together with a clinical sample (n = 93), were used to validate the abbreviated scale. The abbreviated version of the SCAS contained 19 items, it showed a clear factor structure as evaluated in the independent sample, and it performed as good as the original questionnaire regarding classification accuracy, convergent, and divergent validity. In our view, the abbreviated version is a very good alternative to the original scale especially for younger children, in initial screening, or in order to reduce response burden.

Long-term Outcome of a Cluster-Randomized Universal Prevention Trial Targeting Anxiety and Depression in School Children

The present study concerns a 3-year follow-up of a universal prevention trial targeting anxiety and depressive symptoms in school children. In addition to evaluating the long-term effect of the prevention program, we also examined attrition and its effect on the outcome. High rates of attrition have commonly been observed in studies in the field. However, the role of attrition is not sufficiently understood regarding internal and external validity biases. The current study comprised 695 children (aged 8-11 at baseline) from 17 schools in Sweden. Schools were cluster-randomized to either the intervention or control condition. Children completed measures of anxiety and depressive symptoms and parents completed measures of their childs anxiety and general mental health. We found no evidence of long-term effects of the prevention program, except for a small effect regarding parent reports of child anxiety. However, that effect was not found to be of clinical significance. Regarding attrition, children with missing data at the 3-year follow-up displayed higher levels of psychiatric symptoms at baseline and increasing symptoms across time. Furthermore, children in the control condition with missing follow-up data were found to be significantly deteriorated across time compared to the corresponding children in the intervention condition regarding depressive symptoms and total difficulties. In other words, attrition served as a moderator of the effect, which suggests that the overall result was biased toward a null-result. Our study highlights that large and nonrandom attrition severely limits the validity of the results. Further, given the common problem of retaining participants in long-term evaluations of school-based prevention trials, previous studies may suffer from the same limitations as the current study.