Evaluating the real-world effectiveness of a cognitive behavior therapy-based transdiagnostic program for emotional problems in children in a regular school setting

Effectiveness of a transdiagnostic computerized self-applied program targeting children with emotional problems: A randomized controlled trial

BACKGROUND

Super Skills for Life (SSL) is an eight-session transdiagnostic program based on cognitive-behavioral therapy (CBT), aimed at the indicated prevention of childhood emotional problems, which has been implemented with positive short- and long-term results. The present study aimed to examine the effects of a self-applied computerized program based on SSL that maintains the same objectives and contents as the face-to-face program.

METHODS

In this randomized controlled study, 75 children (49.3 % female) aged 8-12 years (Mage = 9.45, SD = 1.31), selected for exhibiting emotional symptoms, were randomly assigned to either the intervention (n = 35) or the waiting list control (WLC) group (n = 40). Pre- and post-intervention data were collected through self-reports and the report of parents who completed parallel versions of the same measures of emotional and behavioral problems.

RESULTS

Overall, compared to the WLC group, the intervention group showed positive effects on targeted emotional symptomatology in the short term. Based on parents' reports, a significant reduction was found in outcomes such as anxiety, depression, emotional symptoms, and internalizing problems, while self-reported results were similar except for anxiety. In addition, a positive impact was found on symptoms related to other types of difficulties (e.g., externalizing problems and general difficulties measured).

LIMITATIONS

Small sample size, non-inclusion of follow-up assessment and other informants (e.g., teachers).

CONCLUSIONS

In conclusion, this research provides novel and promising data on the self-applied computerized adapted version of the SSL program, within a multi-informant approach, suggesting that it may be a useful tool for the indicated prevention of childhood emotional problems.

Is Psychological Distress a Risk Factor or an Outcome of School Violence and Cyberbullying Perpetrated by Adolescents? A Short-Term Longitudinal Panel Study

Although the associations between adolescent psychological distress (i.e., depression, anxiety, and somatization), school violence, and cyberbullying have been examined using cross-sectional data, little evidence from longitudinal panel data exists to determine the temporal association. A two-wave longitudinal panel data with a 10-month interval were obtained from a random sample of 487 Chinese junior high school students (grades 7-9) in Tianjin in Mainland China. The cross-lagged panel analysis showed that adolescent psychological distress in the first wave of the survey was significantly associated with subsequent school violence against peers and teachers in the second wave but not in the opposite direction. Student psychological distress in the first wave of the survey was not significantly associated with cyberbullying perpetration in the second wave and vice versa. The findings suggested that adolescent psychological distress was a risk factor rather than the consequence of violence against peers and teachers in school. However, the temporal associations between adolescent psychological distress and cyberbullying perpetration were non-significant. These findings were relevant to both sex groups. The findings may imply that potential interventions and policies to prevent students from committing school violence should consider reducing students' psychological distress as one of the core elements.

Relationships between psychological flexibility and internet gaming disorder among adolescents: Mediation effects of depression and maladaptive cognitions

Psychological flexibility may reduce addictive behaviours by adaptive and flexible emotional and cognitive processes. This study tested a mediation model of internet gaming disorder (IGD) in which psychological flexibility would reduce depression and maladaptive cognitions related to internet gaming and in turn lower the risk of IGD. A cross-sectional study surveyed 2102 secondary 1-4 students from seven schools during March to November 2021 in Hong Kong, China. The results showed that 12.7% and 52.2% of the students were classified as having probable IGD and depression, respectively. The proposed mediation model fitted the data well: χ2/df = 8.00, CFI = .99, NNFI = .99, RMSEA = .01. Psychological inflexibility was directly and positively associated with IGD (B = .01, β = .07, p = .003) and indirectly and positively associated with IGD via depressive symptoms (B = .01, β = .07, p = .001, PM = 23.7%) and maladaptive cognitions (B = .03, β = .15, p = .001, PM = 50.8%). Multi-group analyses showed that gender significantly moderated the associations between psychological inflexibility and maladaptive cognitions (Δχ2/Δdf = 8.69/1, p < .05), between maladaptive cognitions and IGD (Δχ2/Δdf = 4.33/1, p < .05), and between psychological inflexibility and IGD (Δχ2/Δdf = 5.46/1, p < .05). Depression and maladaptive cognitions may be significant mediators that could explain the relationship between psychological flexibility and IGD. Also, gender difference may exist. Based on the findings, intervention strategies for IGD reduction are discussed.

The Role of Emotion Regulation and Executive Functioning in the Intervention Outcome of Children with Emotional and Behavioural Problems

Emotional and behavioural problems are closely associated with impairments in regulating emotions and in executive functions (EF). To examine this further, the aim of the present study was to determine whether EF and emotion regulation at baseline would predict emotional and behavioural problem scores post-intervention, and further explore the extent to which emotion regulation mediates these outcomes. Participants were 41 primary school children who exhibited emotional and/or behavioural problems, aged 8 to 11 years. All the children completed measures of emotional and behavioural problems, cognitive emotion regulation, anxiety symptoms, and performed two experimental tasks to measure working memory and response inhibition before and after participating in a transdiagnostic Cognitive Behaviour Therapy-based programme, "Super Skills for Life" (SSL), and at 3-months follow-up. Results revealed significant reduction in the use of maladaptive emotion regulation strategy catastrophising and other blame following the intervention. Additionally, EF and emotion regulation was associated with outcomes for emotional problems and conduct problems. More specifically maladaptive emotion regulation strategy such as catastrophising and other blame was closely related with self-reports of emotional problems, likewise other blame, was also linked with scores of conduct problems. This study provides preliminary empirical support for EF and emotion regulation in predicting outcomes of emotional and behavioural problems in children following intervention.

School-based cognitive-behavioural therapy for children and adolescents with social anxiety disorder and social anxiety symptoms: A systematic review

BACKGROUND

Social anxiety disorder (SAD) is prevalent among children and adolescents. Cognitive-behavioural therapy (CBT) has been used as the first-line treatment. However, evaluation of CBT conducted in a school setting has been scarce.

OBJECTIVES

This study aims to review the CBT and its effectiveness in the school setting for children and adolescents with SAD or social anxiety symptoms. Quality assessment on individual studies was conducted.

METHODS

Studies were identified through the search in PsycINFO, ERIC, PubMed and Medline targeting CBT conducted in a school setting with an aim to treat children and adolescents with SAD or social anxiety symptoms. Randomised controlled trials and quasi-experimental studies were selected.

RESULTS

A total of 7 studies met the inclusion criteria. Five studies were randomised controlled trials, and two were quasi-experimental studies with 2558 participants aged 6-16 years from 138 primary schools and 20 secondary schools. There were minor effects to reduce social anxiety symptoms for children and adolescents at post-intervention in 86% of the selected studies. Friend for Life (FRIENDS), Super Skills for Life (SSL) and Skills for Academic and Social Success (SASS) conducted in school were more effective than the control conditions.

CONCLUSIONS

There is a lack of quality of the evidence for FRIENDS, SSL and SASS, due to inconsistencies on the outcome assessments, statistical analyses, and the fidelity measures adopted in individual studies. Insufficient school funding and workforce with relevant health background, and the low level of parental involvement in the intervention would be the major challenges in school-based CBT for children and adolescents with SAD or social anxiety symptoms.

Implementation of a Transdiagnostic Universal Prevention Program on Anxiety in Junior High School Students After School Closure During the COVID-19 Pandemic

School closures due to the coronavirus disease 2019 (COVID-19) pandemic have worsened mental health problems for children and adolescents worldwide. We aimed to examine the follow-up effectiveness of a transdiagnostic universal prevention program for anxiety of junior high school students after a nationwide school closure during the COVID-19 outbreak in Japan. A total of 117 junior high school students were included in the analysis. We used the Unified Universal Prevention Program for Diverse Disorders (Up2-D2) program; the Up2-D2 comprises cognitive-behavioral and positive psychological interventions provided over twelve 45-minute sessions. The program was originally implemented between June and July 2020, immediately after pandemic-related school closures had ended in Japan. The program assessments were based on students' responses to a questionnaire incorporating five scales to measure indicators such as internalizing and externalizing problems. Assessments were carried out before, immediately after, two-month, and six-month after implementing the program. Mixed models for the whole sample showed small anxiety improvement effects immediately post-intervention and two-month, and six-month assessments (g = -0.25, g = -0.44, and g = -0.30, respectively). The anxiety reducing effects were even greater for the higher-anxiety group at the post-, 2-month, and 6-month assessments (g = -1.48; g = -1.59; g = -1.06, respectively). Although there was no control group, these results indicate that the transdiagnostic universal prevention intervention reduce only anxiety, but not other outcomes (depression, anger, and self-efficacy) in junior high students returning to school following school closures related to the COVID-19 pandemic in Japan.

Acceptability and Feasibility of the ProLiSMental Psychoeducational Intervention to Promote Adolescents' Mental Health Literacy on Anxiety in a School Context

The ProLiSMental psychoeducational intervention intends to promote adolescents' mental health literacy on anxiety, facilitating their access, understanding, evaluation, and use of effective mental health information. This study aimed to assess the acceptability and feasibility of that intervention in a school context and improve its content, structure, and procedure. A convenience sample of seventeen participants has been recruited: eleven students (mean age = 14.09 years, SD = 0,30) and six education and health professionals (mean age = 53.00 years, SD = 4,05). High levels of acceptability and feasibility of the ProLiSMental psychoeducational intervention were observed and important improvements were made.

Evaluating the effectiveness of a transdiagnostic universal prevention program for both internalizing and externalizing problems in children: two feasibility studies

BACKGROUND

The present study examined the effectiveness of the Universal Unified Prevention Program for Diverse Disorders (Up2-D2) for internalizing and externalizing problems for children aged 9-11 years.

METHODS

We used two feasibility studies. The Up2-D2 entailed 12 sessions delivered by teachers; each session was developed based on cognitive-behavioral and positive psychological interventions. In Studies 1 and 2, 58 elementary school children aged 9-11 and 73 elementary school children aged 10-11 attended the Up2-D2. The teachers in Study 1 received 1.5 h of on-site teacher training for learning rationales for interventions, how to run the program, and received ongoing supervision by professionals with mental health expertise. In contrast, the teachers in Study 2 were given self-learning DVD materials in place of on-site training and ongoing supervision.

RESULTS

Mixed models revealed that general difficulties, which is total score of both internalizing and externalizing problems, decreased in Study 1 but not in Study 2. Additional analyses for children with subclinical general difficulties revealed that general difficulties, internalizing problems, and externalizing problems decreased in Study 1, whereas in Study 2, general difficulties and internalizing problems decreased, except for externalizing problems.

CONCLUSIONS

These results suggest that on-site teacher training and ongoing supervision are imperative for improving general difficulties in children at a universal level. In addition, universal preventive interventions by classroom teachers without on-site training and continuous supervision might be efficacious for reducing general difficulties and internalizing problems for children with subclinical difficulties.

Exploring the impact of a transdiagnostic cognitive behavioural therapy-based intervention on a group of Malaysian adolescents with problematic drug use and emotional problems

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After participating in the intervention, symptoms of emotional problems were significantly reduced.

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There was a significant reduction in substance use and maladaptive emotion regulation strategies after the intervention.

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Girls benefitted significantly more from the intervention compared to boys.

Introduction

Adolescents with problematic substance use frequently have anxiety and depression and tend to have “unhealthy” lifestyle such as having poor dietary patterns and physical inactivity. The overall aim of the present study was to explore the impact of a Transdiagnostic Cognitive Behavioral Therapy-based Intervention (“Super Skills for Life” – adolescent version; SSL-A) on emotional problems among adolescents with problematic substance use and to identify demographic factors which influence the intervention outcomes.

Method

A total of 108 adolescents (M = 16.30 years, SD = 1.6) with problematic substance use who showed high levels of anxiety and depression participated in this study. They completed a set of questionnaires to measure substance use, mental health problems, cognitive emotion regulation strategies, loneliness, and lifestyle and habits at pre- and post-intervention.

Results

The adolescents reported less emotional symptoms and more prosocial behavior after the intervention. These adolescents were also consumed less substance and used less maladaptive emotion regulation strategies after participating in SSL-A. Females compared to males showed more treatment gains (i.e., reduction in loneliness and improvement in psychological health and self-esteem) after the intervention.

Conclusion

This study provides empirical evidence for the utility of the SSL-A in reducing emotional problems and substance use among adolescents with problematic substance use.

Effects as a function of implementation fidelity of a transdiagnostic prevention program in young school-aged children

Super Skills for Life (SSL) is a transdiagnostic prevention program for school-aged children with internalizing problems. The current study aimed to examine the short- and long-term (12-month follow-up) effectiveness of SSL, depending on implementation fidelity. Participants were 123 Spanish-speaking children aged 6-8 years with internalizing symptoms and their parents. High (n = 41) and low fidelity (n = 26) groups were established and compared with a control group (CG) (n = 56). Compared to CG, the high-fidelity group (HFG) achieved better outcomes than the low-fidelity group (LFG) at short and long term, including symptoms of anxiety, depression, and internalizing problems, and also externalizing problems at long-term. The LFG improved key symptoms at short term (depression) and long term (anxiety and depression). Findings suggest that SSL is beneficial even if not delivered at maximum fidelity, although considering the influence of implementation fidelity is critical because the high-fidelity implementation yielded the greatest effects when compared to the CG. This research provides valuable data, analyzing for the first time the influence of fidelity on SSL outcomes in young school-aged children exhibiting internalizing symptoms, while there is still a lack of studies of these characteristics concerning transdiagnostic prevention programs targeting childhood anxiety and depression.

Spanish version of Super Skills for Life in individual modality: Improvement of children's emotional well-being from a transdiagnostic approach

OBJECTIVE(S)

This study analyzed the short-term effects of the Super Skills for Life (SSL) program in its individual format from the parents' perspective.

METHODS

Parents of 70 Spanish children aged 8-11 years (M = 9.31; SD = 1.16) completed assessment instruments about their children's emotional state at the baseline and postintervention.

RESULTS

Analyses revealed significantly lower scores in depression (The Mood and Feelings Questionnaire), anxiety, and specific disorders (The Spence Children's Anxiety Scale) (i.e., panic attack/agoraphobia, separation anxiety, social phobia, and generalized anxiety). Significant improvements were also found in anxiety life interference at home (The Child Anxiety Life Interference Scale), total difficulties, internalized and externalized problems, emotional symptoms, peer problems, and hyperactivity/inattention (The Strengths and Difficulties Questionnaire) at posttest. SSL was effective in reducing psychopathological symptoms similarly in both girls and boys.

CONCLUSIONS

These promising results provide preliminary support for the usefulness of the SSL program in individual format for the indicated prevention of children's emotional problems. This study provides a valuable resource for research and clinical practice.

Effectiveness of the Super Skills for Life programme in enhancing the emotional wellbeing of children and adolescents in residential care institutions in a low- and middle-income country: A randomised waitlist-controlled trial

BACKGROUND

The present study examined the effectiveness of a transdiagnostic prevention programme, Super Skills for Life (SSL), among children and adolescents with emotional problems in residential care institutions (RCIs) in the low- and middle-income country of Mauritius using a randomised waitlist-controlled trial (RCT). SSL is based on the principles of cognitive behavioural therapy, behavioural activation, social skills training, and uses video-feedback and cognitive preparation as part of the treatment.

METHODS

The RCT involved 100 children and adolescents aged 9 to 14 years, from six RCIs, randomly allocated to either an SSL intervention group (IG) or a waitlist-control (WLC) group. A set of questionnaires measuring internalising and externalising problems, emotion regulation and self-esteem, and experimental tasks measuring attentional bias and inhibitory control, were completed at baseline, post-intervention and 3-month follow-up. Participants also completed a 2-min video speech task during the first and final sessions of the SSL intervention.

RESULTS

Children and adolescents in the IG showed significant improvements in internalising symptoms (e.g. anxiety and depression), externalising symptoms (e.g. conduct problems and hyperactivity), and inhibitory control, and an increase in adaptive (except putting into perspective strategy) and decrease in maladaptive emotion regulation strategies, at both post-intervention and follow-up. These findings were not replicated among children in the WLC.

LIMITATIONS

The small sample size and lack of an active control group were the major limitations of this study.

CONCLUSIONS

This study provides evidence for the effectiveness of a transdiagnostic prevention programme for emotional problems in RCIs in a low- and middle-income country.

Evidence Base Update for Measures of Social Skills and Social Competence in Clinical Samples of Youth

Social skills and social competence are key transdiagnostic processes in developmental psychopathology and are the focus of an array of clinical interventions. In this Evidence Base Update, we evaluated the psychometric properties of measures of social skills and social competence used with clinical samples of children and adolescents. A systematic literature search yielded eight widely used measures of social skills and one measure of social competence. Applying the criteria identified by Youngstrom et al. (2017), we found that, with some exceptions, these measures had adequate to excellent norms, internal consistency, and test-retest reliability. There was at least adequate evidence of construct validity and treatment sensitivity in clinical samples for nearly all measures assessed. Many of the scales included items assessing constructs other than social skills and competence (e.g., emotion regulation). Development of updated tools to assess youth's effectiveness in key interpersonal situations, including those occurring online, may yield clinical dividends.

A 12-month follow-up of a transdiagnostic indicated prevention of internalizing symptoms in school-aged children: the results from the EMOTION study

BACKGROUND

Anxious and depressive symptoms in youth are highly prevalent, are often comorbid and have a high rate of relapse. Preventive interventions are promising, but follow-up results are lacking. The transdiagnostic EMOTION program is an indicated preventive cognitive behavioral therapy (CBT) intervention targeting children aged 8-12 years.

METHODS

The present study investigates the 12 months follow-up effects of the EMOTION intervention in a cluster randomized controlled trial (RCT) with 795 children that included both child self-reports and parental reports.

RESULTS

Mixed model analyses showed a larger decrease of symptoms in the intervention group than in the control group for child self-reported anxious symptoms (The Multidimensional Anxiety Scale for Children (MASC) difference 4.56, CI 1.83 to 7.29, p = .001). Parental reports for both anxious (MASC difference 2.50, CI .26 to 4.74, p = .029) and depressive (The Mood and Feelings Questionnaire-short form (SMFQ) difference 1.55, CI .83 to 2.26, p ≤ .001) symptoms in children also showed a reduction. No statistically significant difference was found for child self-reported depressive symptoms (SMFQ difference .69, CI - .22 to 1.60, p = .139).

CONCLUSION

The transdiagnostic EMOTION program has shown the potential for long-term reductions in symptoms of both anxiety and depression in school-aged children. However, results regarding depressive symptoms must be considered preliminary as only parental report indicated effect.Trial registration The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov Identifier; NCT02340637.

Effectiveness of Video-Feedback with Cognitive Preparation in Improving Social Performance and Anxiety through Super Skills for Life Programme Implemented in a School Setting

Effectiveness of video-feedback with cognitive preparation to treat anxiety problems (especially social anxiety) has been scarcely explored on children. Super Skills for Life (SSL) is a CBT-based intervention to reduce anxiety and comorbid problems that, apart from social skills training and behavioural activation, integrates video-feedback with cognitive preparation. This study aimed to evaluate SSL effects, implemented in a school setting, on social performance and to test self-concept and social skills as potential mediators of pre- and post-test changes in social anxiety and generalized anxiety. Sample comprised 57 children aged 8-11 years with emotional symptoms. Children were video recorded in the first and last session to assess social performance. Anxiety and self-concept measures were completed by children pre-test and post-test. Participants reduced anxiety behaviours and improved social and communication skills after treatment. In general, girls showed better social performance than boys, but SSL impact was greater in males. Social self-concept was the only mediator of change in pre- to post-treatment social anxiety. This study provides evidence of SSL to improve children's social performance and reduce anxiety through video-feedback with cognitive preparation. Improving social concept seems essential to reduce social anxiety. An SSL programme is an ideal prevention protocol for anxious children.

Effects of a transdiagnostic cognitive behaviour therapy-based programme on the natural course of anxiety symptoms in adolescence

BACKGROUND

Anxiety disorders frequently have an onset during adolescence, which when left untreated could lead to a chronic course and outcome. This study aimed to examine the way in which a cognitive behaviour therapy-based programme (Super Skills for Life - adolescent version; SSL-A) could change the course of anxiety symptoms through adolescent's behavioural performance and cardiac function.

METHOD

Sixty-one adolescents at risk of developing an anxiety disorder (45.30% boys; M = 13.76 years, SD = 0.32) were randomly assigned to either an intervention (IG), placebo (PG), or a waitlist group (WG). Adolescents in the IG participated in SSL-A over an 8-week period. Adolescents in the PG participated in an 8-session school-work programme. Adolescents in the WG did not receive any intervention. Anxiety symptoms were assessed every six months, twice before the intervention, as well as at the post-intervention and six months after the intervention. Participants in the IG additionally underwent a stressful task to assess behavioural performance and cardiac adjustment.

RESULTS

Adolescents in the IG significantly reported lower levels of social phobia and generalised anxiety symptoms at the follow-up assessment compared to the adolescents in the PG and the WG. They also showed a significant improvement in vocal quality and lower discomfort during a stressful task at post-intervention, and showed attenuated cardiac recovery indexes, in terms of sample entropy.

LIMITATIONS

The study has a small sample size.

CONCLUSION

SSL-A changed the natural course of anxiety symptoms, as shown by a significant reduction in social phobia and generalised anxiety symptoms, and a significant improvement in behaviour and physiological (cardiac) function during a stressful situation.

One-Year follow-up effects of a cognitive behavior therapy-based transdiagnostic program for emotional problems in young children: A school-based cluster-randomized controlled trial

BACKGROUND

The present study examined the long-term efficacy of a transdiagnostic prevention program, Super Skills for Life (SSL), among young children with emotional problems. SSL is based on the principles of cognitive behavioral therapy, behavioral activation, and social skills training.

METHODS

One-hundred and twenty-three Spanish-speaking children, aged 6 to 8 years, and their parents participated in the study. They were recruited from ten schools. Schools were randomly allocated to either the intervention (IG) or waiting-list control (WLC) groups. The children's parent completed a set of questionnaires to measure their child's anxiety and depressive symptoms, general difficulties and positive attributes, and psychosocial impairment. Parent's assessment at baseline and at a 12-month follow-up was assessed using an intent-to-treat approach.

RESULTS

The IG, compared to WLC group, showed significant baseline-to-follow-up reductions in anxiety and depressive symptoms, as well as in behavioral difficulties and psychosocial impairment in various life domains.

LIMITATIONS

The small sample size and the reliance on parental reports were the major limitations of this study.

CONCLUSIONS

This study provides initial evidence of the long-term effects of SSL, suggesting that it is a promising indicated preventive intervention for young children with emotional problems.