Annual Research Review: Expanding mental health services through novel models of intervention delivery

Effectiveness of an unguided modular online intervention for highly anxious parents in preventing anxiety in their children: a parallel group randomised controlled trial

Background

Children whose parents have anxiety problems are at increased risk of developing anxiety themselves. Parenting behaviors are a contributing factor to intergenerational transmission. Interventions which seek to limit anxiogenic parenting behaviors have shown potential in reducing anxiety in offspring but are not widely accessible. This prevention trial aimed to establish the effectiveness of an unguided modular online intervention for highly anxious parents in preventing anxiety in their children.

Methods

A parallel group, block-randomised controlled trial of unblinded participants in a 1:1 ratio was conducted to compare efficacy of the online course compared to a no-intervention control. The intervention comprised 8 modules, of approximately 20 min each, and participants progressed through the course at their own pace. The study was conducted entirely online with a self-referred UK-based community sample of parents (child 2-11 years) with substantial anxiety. The primary outcome measure was change in parent-reported child anxiety, as measured by the Spence Children's Anxiety Scale-Parent Report (SCAS-P) or Spence Pre-School Anxiety Scale-Parent Report (Preschool SCAS). Secondary outcomes were child internalising, externalising, and attentional symptoms (Pediatric Symptom Checklist), and parent anxiety (SCARED-Adult). Analyses using complete case analysis following intention to treat principles investigated intervention effects at 6 months (primary analysis) and additionally at 9 to 25-months' follow-up. Trial registration: ClinicalTrials.GovNCT04755933, https://clinicaltrials.gov/ct2/show/NCT04755933.

Findings

1811 participants (intervention = 900; control = 911; 92.7% (1677/1810) female; 85.3% (1535/1800) White-British; 66.8% (1201/1799) university educated). Participant retention (based on primary outcome completion) at T2 (6-months post consent) was 67.6% overall (n = 1224) and substantially lower in the intervention arm 57.3% ((516/900) control = 77.8% (708/910)). Child anxiety was lower in the intervention group compared to control at 6-month follow-up (adjusted effect size estimate -0.15 (95% CI: -0.23 to -0.08, p < 0.001). There was very strong evidence that those in the intervention arm had lowered child anxiety (standardised SCAS score) compared to the control arm, with an effect size (Cohen's d) of -0.16 (95% CI: -0.23 to -0.08, p < 0.001). The difference in standardised Spence Child Anxiety Scale score between the arms was -0.15 standard deviations. On the original scales for SCAS-P (0-114) and Preschool SCAS (0-112), this corresponds to a reduction of -2.38 (95% CI: -3.59 to -1.16) and -2.68 (95% CI: -4.05 to -1.31), respectively. No reported harms.

Interpretation

A clinically unsupported online intervention designed for parents with high levels of anxiety is effective in reducing anxiety and internalising symptoms in their children, and also anxiety in parents. Given the low resource intensity of this intervention, and the positive effects reported here, these findings suggest it has promise in limiting the intergenerational transmission of severe anxiety.

Funding

This work was supported by Kavli Trust (grant 38/19).

Is There a Place for Cognitive Restructuring in Brief, Self-Guided Interventions? Randomized Controlled Trial of a Single-Session, Digital Program for Adolescents

OBJECTIVE

Self-guided digital mental health interventions (DMHIs) teaching empirically supported skills (e.g. behavioral activation) have demonstrated efficacy for improving youth mental health, but we lack evidence for the complex skill of cognitive restructuring (CR).

METHOD

We conducted the first-ever RCT testing a CR DMHI ("Project Think") against an active control (supportive therapy; "Project Share") in collaboration with public schools. Pre-registered outcomes were DMHI acceptability and helpfulness post-intervention, as well as internalizing symptoms and CR skills use from baseline to seven-month follow-up, in the full sample and the subsample with elevated symptoms.

RESULTS

Participants (N = 597; MAge = 11.99; 48% female; 68% White) rated both programs highly on acceptability and helpfulness. Both conditions were associated with significant internalizing symptom reductions across time in both samples, with no significant condition differences. CR skills use declined significantly across time for Project Share youths but held steady across time for Project Think youths in both samples; this pattern produced a significant condition difference favoring Project Think within the elevated sample at seven-month follow-up.

CONCLUSION

Internalizing symptoms declined comparably for Think and Share participants. Consequently, future research should examine whether encouraging youths to share their feelings produces symptom improvements, and whether a single-session, self-guided CR DMHI produces beneficial effects relative to more inert control conditions. Further, the decline in CR skills use for Project Share youths versus sustained CR use by Project Think youths raises questions about the natural time course of youths' CR use and the impact of these DMHIs on that course. ClinicalTrials.gov Registration: NCT04806321.

Efficacy of a transdiagnostic Internet prevention approach in adolescents (EMPATIA study): study protocol of a randomized controlled trial

BACKGROUND

Most mental disorders have their onset in adolescence. Preventive interventions during this period are important; however, help-seeking behavior is generally poor in this age group resulting in low treatment rates. Internet interventions are expected to be an effective, low-threshold, and scalable approach to overcome barriers to help-seeking, particularly for individuals experiencing subclinical symptoms. Internet-delivered indicated prevention seems promising as it targets individuals with minimal symptoms of mental disorders who might need care but are not help-seeking yet. Previous indicated prevention-approaches have mainly targeted specific risk-syndromes. However, this contradicts the increasing recognition of emerging psychopathology as a complex system characterized by co-occurrence and rapid shifts of subclinical symptoms cutting across diagnostic categories. Therefore, this study will investigate the efficacy, mediators, moderators, and core symptomatic changes of a transdiagnostic Internet-delivered indicated prevention program (EMPATIA program) for adolescents.

METHODS

This randomized controlled trial (RCT) will be conducted in a general population sample (planned n = 152) of adolescents aged 12-18 years with subclinical symptoms but without any current or past mental disorder. Participants will be randomly assigned to the EMPATIA program or a care as usual (CAU) control condition. The 8-week guided EMPATIA program encompasses 8 modules targeting the following transdiagnostic mechanisms: repetitive negative thinking, self-perfectionism, emotion regulation, intolerance of uncertainty, rejection sensitivity, and behavioral avoidance. Participants will be asked to answer online self-report questionnaires at baseline, after 8 weeks, and at 6-, 9-, and 12-month follow-up. Diagnostic telephone interviews will be conducted at baseline and at 12-month follow-up. Additionally, intervention-specific constructs (motivation, alliance, negative effects, satisfaction, adherence) will be assessed during and after the EMPATIA program. The level of self-reported general psychopathology post-intervention is the primary outcome.

DISCUSSION

Results will be discussed considering the potential of Internet interventions as a scalable, low-threshold option for indicated prevention in adolescents experiencing subclinical symptoms. The EMPATIA program introduces a novel Internet prevention program targeting six transdiagnostic mechanisms associated with various mental health outcomes. Thereby, this trial pursues a very timely and important topic because it may contribute to narrow the current care gap for adolescents, to prevent mental health problems and related negative consequences, and to promote mental health in the long-term.

TRIAL REGISTRATION

The trial was approved by Swissmedic (Registration Number: 10001035, 08/22/2022) and the Ethics Committee of Bern (Registration Number: 2022-D0036, 08/22/2022). The trial was registered at ClinicalTrials.gov NCT05934019 on 07-03-2023.

Training and supervision of physical health professionals to implement mental health care in paediatric epilepsy clinics

BACKGROUND

Children and young people with epilepsy are more likely to experience multiple mental health problems than those without chronic physical health conditions, yet they often do not receive evidence-based (or indeed any) psychological interventions. Integrated healthcare is recommended as a solution to address these inequalities, but remains limited in the United Kingdom. This is partly due to the lack of training and availability of ongoing supervision for clinicians to ensure the safe and effective delivery of treatments. This study aimed to train and provide supervision for health professionals to deliver a modular cognitive-behavioural intervention for common mental health problems, optimised for use in paediatric epilepsy. Specifically, this study aimed to measure therapist competence and evaluate the acceptability of training and supervision.

METHODS

Fifteen health professionals working in paediatric epilepsy services were trained over a six-month period. Training included face-to-face training workshops and completing at least one training case of a young person with epilepsy and anxiety, depression and/or behavioural problems under close clinical supervision. Throughout the training, health professionals were offered weekly one-hour supervisions with an experienced Clinical Psychologist. Clinical competence was assessed using a widely used measure of therapist competence in cognitive-behavioural therapy. Rates of attendance at supervision sessions and therapist ratings of satisfaction were recorded.

RESULTS

At the end of the six-month training, 14 health professionals reached clinical competence in delivering the mental health intervention. One person left the service and therefore did not complete the training. Overall, health professionals were satisfied with the training and supervision. However, 14 % of supervision sessions were cancelled and a further 11 % were not attended. Supervision sessions were also often shorter than the standard hour used in mental health settings (M = 41.18 min, SD = 10.30).

CONCLUSIONS

Our findings suggest that health professionals working in paediatric epilepsy services can be trained to deliver a psychological intervention with proficiency. However, the supervision model typically used in mental health may need adaptation to be sustainable in physical health settings. Future research is needed to evaluate the impact of training and supervision on patient outcomes and to ensure that ethical delivery of psychological interventions by health professionals without a mental health background.

Intervention for school anxiety and absenteeism in children (ISAAC): Co-designing a brief parent-focused intervention for emotionally-based school avoidance

Emotionally-based school avoidance (EBSA) is an important driver of persistent school absenteeism and may have worsened in the context of COVID-19. This paper describes the development of a brief parent-focused psychosocial intervention with the goal to address the lack of accessible early interventions for EBSA. The developmental process used a person-based approach with two phases. In Phase 1, qualitative data were collected about intervention preferences and priorities from N = 10 parents and N = 7 practitioners in a series of co-design workshops. Phase 2 refined an intervention blueprint based on iterative consultations with N = 4 parents and N = 3 practitioners. Framework analysis was used to organise findings around key intervention parameters, including relevant mechanisms, content, and delivery methods needed to provide effective, acceptable and feasible support for families affected by EBSA. The resulting blueprint incorporates three online modules to be delivered over three weeks with each module consisting of psychoeducational videos, self-completed learning tasks and a corresponding coaching session. Respective module content includes: (i) self-care strategies to increase parent wellbeing and self-efficacy; (ii) parenting strategies to change behavioural patterns that maintain child distress and avoidance of school; and (iii) strategic communication strategies to increase the quality of home-school relationships. The blueprint has been developed into a full prototype for a forthcoming feasibility study.

Brief School-Based Interventions Targeting Student Mental Health or Well-Being: A Systematic Review and Meta-Analysis

Brief, school-based mental health interventions hold promise for reducing barriers to mental health support access, a critical endeavor in light of increasing rates of mental health concerns among youth. However, there is no consensus on whether or not brief school-based interventions are effective at reducing mental health concerns or improving well-being. This systematic review and meta-analysis aims to provide consensus and determine directions for future work. Articles were included if they examined a brief (≤ four sessions or 240 min of intervention time) psychosocial intervention, were conducted within a Pre-K through 12th-grade school setting, included at least one treatment outcome evaluating mental health or well-being, and were published since 2000. A total of 6,702 papers were identified through database searching, of which 81 papers (k studies = 75) were ultimately selected for inclusion. A total of 40,498 students were included across studies and a total of 75 unique interventions were examined. A total of 324 effect sizes were extracted. On average, interventions led to statistically significant improvements in mental health/well-being outcomes versus control conditions up to one-month (g = .18, p = .004), six-month (g = .15, p = .006), and one-year (g = .10, p = .03) post-intervention. There may be benefits to brief school-based interventions from a preventative public health standpoint; future research may focus on how to optimize their real-world utility. Prospero pre-registration: CRD42021255079.

Patterns of unhealthy lifestyle and their associations with depressive and anxiety symptoms among Chinese young adults: A latent class analysis

BACKGROUND

There is little evidence on the association between patterns of unhealthy lifestyle and mental health among young adults.

METHOD

This study included a total of 28,978 young adults aged 18 to 44 years old in Guangdong province in south China, which was conducted from September to December in 2022. We used latent class analysis to classify the patterns of unhealthy lifestyle among young adults and used multiple logistic regression to explore their associations with depressive and anxiety symptoms.

RESULT

The weighted prevalence of depressive and anxiety symptoms were 28.0 % and 19.5 %, respectively. The cumulative effect of unhealthy lifestyles on depressive and anxiety symptoms was significant. Five patterns of unhealthy lifestyle were classified. Compared to the relatively healthy lifestyle class, the class with more unhealthy lifestyles (OR = 6.54, 95 % CI: 5.70-7.51) and insufficient sleep (OR = 6.16, 95 % CI: 4.92-7.70) had higher risk for depressive and anxiety symptoms. Meaningfully, having adequate mental health literacy could reduce the risk of depressive and anxiety symptoms from unhealthy lifestyle by half.

LIMITATIONS

The cross-section design study limited causal inferences, and the self-report information may lead to recall bias.

CONCLUSIONS

Unhealthy lifestyles have a negative impact on depressive and anxiety symptoms through independent, cumulative and combined effects, and they could be interrelated. Unhealthy lifestyle patterns differed in younger population by socio-demographic characteristics and mental health literacy. Health-care professionals and policymakers may provide programs to intervene multiple unhealthy lifestyles and improve mental health literacy by integrating healthy lifestyle education to promote youngers' mental health.

Efficacy of Internet-based rumination-focused cognitive behavioral therapy and mindfulness-based intervention with guided support in reducing risks of depression and anxiety: A randomized controlled trial

Rumination and worry are common risk factors of depression and anxiety. Internet-based transdiagnostic interventions targeting individuals with these specific risks may be an effective way to prevent depression and anxiety. This three-arm randomized controlled trial compared the efficacy of Internet-based rumination-focused cognitive behavioral therapy (RFCBT), mindfulness-based intervention (MBI), and psychoeducation (EDU) control among 256 at-risk individuals. Participants' levels of rumination, worry, depressive, and anxiety symptoms were assessed at post-intervention (6 weeks), 3-month, and 9-month follow-ups. Linear mixed model analysis results showed similar levels of improvement in all outcomes across the three conditions. Changes in rumination differed comparing RFCBT and MBI, where a significant reduction in rumination was noted at a 3-month follow-up among participants in RFCBT, and no significant long-term effect among participants in MBI was noted at a 9-month follow-up. All three conditions showed similar reductions in risks and symptoms, implying that the two active interventions were not superior to EDU control. The high attrition at follow-ups suggested a need to exercise caution when interpreting the findings. Future studies should tease apart placebo effect and identify ways to improve adherence.

Perfect storm: emotionally based school avoidance in the post-COVID-19 pandemic context

School absences have risen following the COVID-19 pandemic and persistent absenteeism remains high in primary and secondary schools in England compared with pre-pandemic levels. This coincides with an upward trend in emotionally based school avoidance (EBSA). EBSA adversely affects children's educational attainment, health, social functioning and life prospects and warrants early intervention before a pattern of absenteeism becomes entrenched. In this article, we consider how the COVID-19 pandemic and its sequelae have created a 'perfect storm' of conditions, amplifying known school, family and child-based risk factors for EBSA while simultaneously reducing access to support services. We then outline priorities for developing new EBSA interventions and argue for a multi-component approach, which works across education, health and social care, and voluntary sectors to address the complex interplay between risk factors. Given the difficulties that families often face in obtaining timely support for EBSA, it is also essential that new interventions are accessible, resource-efficient and scalable. To this end, we specifically discuss the potential for contextually-sensitive, parent-focused interventions that can be delivered online with minimal synchronous support from a trained coach or facilitator.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Stepped-Care Cognitive Behavioral Therapy in Children on the Autism Spectrum with Co-occurring Anxiety

This trial examined stepped-care cognitive-behavioral treatment (CBT) among 96 autistic youth with co-occurring anxiety. Step 1 included an open trial of parent-led, therapist-guided bibliotherapy. Step 2 was family-based CBT for those who did not respond to Step 1 or maintenance for those who did. Eighteen participants (28%) who completed Step 1 responded. Responders reported significantly lower pre-treatment anxiety, internalizing symptoms, and functional impairment than non-responders. After Steps 1 and 2, 80% of completers (55% intent-to-treat) were responders. Anxiety, impairment, and ASD-related impairments significantly improved. Youth in maintenance experienced faster improvement through post-treatment, though there were no group differences at 3-month-follow-up. A stepped approach may help some individuals in Step 1, particularly those who are less anxious.

The Effects of a Digital, Transdiagnostic, Clinically and Peer-Moderated Treatment Platform for Young People With Emerging Mental Health Complaints: Repeated Measures Within-Subjects Study

BACKGROUND

To address the growing prevalence of youth mental health problems, early intervention is crucial to minimize individual, societal, and economic impacts. Indicative prevention aims to target emerging mental health complaints before the onset of a full-blown disorder. When intervening at this early stage, individuals are more responsive to treatment, resulting in cost-effective outcomes. The Moderated Online Social Therapy platform, which was successfully implemented and proven effective in Australia, is a digital, peer- and clinically moderated treatment platform designed for young people. The Netherlands was the first country outside Australia to implement this platform, under the name Engage Young People Early (ENYOY). It has the potential to reduce the likelihood of young people developing serious mental health disorders.

OBJECTIVE

This study aims to investigate the effects on young people using the ENYOY-platform in relation to psychological distress, psychosocial functioning, and positive health parameters.

METHODS

Dutch-speaking young people with emerging mental health complaints (N=131) participated in the ENYOY-platform for 6 months in a repeated measures within-subjects study. Psychological distress, psychosocial functioning, and positive health parameters were assessed at baseline and 3, 6, and 12 months. Repeated measures ANOVA was conducted and adjusted for age, sex, therapy, and community activity. The Reliable Change Index and Clinically Significant Index were computed to compare the baseline with the 6- and 12-month measurements. The missing data rate was 22.54% and the dropout rate 62.6% (82/131).

RESULTS

The primary analysis (77/131, 58.8%) showed that psychological distress decreased and psychosocial functioning improved over time with large effect sizes (P<.001 in both cases; ηp2=0.239 and 0.318, respectively) independent of age (P=.76 for psychological distress and P=.48 for psychosocial functioning), sex (P=.24 and P=.88, respectively), therapy activity (P=.49 and P=.80, respectively), or community activity (P=.59 and P=.48, respectively). Similarly, secondary analyses (51/131, 38.9%) showed significant effects of time on the quality of life, well-being, and meaningfulness positive health parameters (P<.05; ηp2=0.062, 0.140, and 0.121, respectively). Improvements in all outcome measures were found between baseline and 3 and 6 months (P≤.001-.01; d=0.23-0.62) and sustained at follow-up (P=.18-.97; d=0.01-0.16). The Reliable Change Index indicated psychological distress improvements in 38% (39/102) of cases, no change in 54.9% (56/102) of cases, and worsening in 5.9% (6/102) of cases. Regarding psychosocial functioning, the percentages were 50% (51/102), 43.1% (44/102), and 6.9% (7/102), respectively. The Clinically Significant Index demonstrated clinically significant changes in 75.5% (77/102) of cases for distress and 89.2% (91/102) for functioning.

CONCLUSIONS

This trial demonstrated that the ENYOY-platform holds promise as a transdiagnostic intervention for addressing emerging mental health complaints among young people in the Netherlands and laid the groundwork for further clinical research. It would be of great relevance to expand the population on and service delivery of the platform.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-021-03315-x.

The effectiveness of community friendship groups on participant social and mental health: a meta-analysis

Introduction

Social disconnectedness and isolation are risk factors for poor mental health. Community-based friendship group interventions have been designed to increase an individual's social capital and consequently their mental wellbeing. Structured and unstructured friendship groups reflect two distinct approaches to friendship group interventions.

Methods

This meta-analysis investigated whether structured or unstructured community friendship groups are more effective for mental health and social capital outcomes. A systematic search of quantitative studies was conducted across seven databases and study quality was assessed using the Effective Public Health Practice Project (EPHPP) tool. Eight studies (2 unstructured and 6 structured friendship groups) were included in the review, published between 2005 and 2020.

Results

Structured friendship groups had a small significant effect on reducing participant depression symptoms. There was not enough available data to compare the effectiveness of structured and unstructured groups for mental health outcomes. There was substantial heterogeneity between studies to calculate pooled effect sizes for any social capital outcomes. Data synthesis indicated mixed reviews for social capital outcomes, likely due to the large heterogeneity and limited studies.

Discussion

This meta-analysis provides limited support for positive mental health outcomes following structured community-based friendship group interventions. There is a need for additional research as a large research gap remains, particularly for unstructured friendship groups.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=260639, CRD42021260639.

Safety of Large Language Models in Addressing Depression

Background Generative artificial intelligence (AI) models, exemplified by systems such as ChatGPT, Bard, and Anthropic, are currently under intense investigation for their potential to address existing gaps in mental health support. One implementation of these large language models involves the development of mental health-focused conversational agents, which utilize pre-structured prompts to facilitate user interaction without requiring specialized knowledge in prompt engineering. However, uncertainties persist regarding the safety and efficacy of these agents in recognizing severe depression and suicidal tendencies. Given the well-established correlation between the severity of depression and the risk of suicide, improperly calibrated conversational agents may inadequately identify and respond to crises. Consequently, it is crucial to investigate whether publicly accessible repositories of mental health-focused conversational agents can consistently and safely address crisis scenarios before considering their adoption in clinical settings. This study assesses the safety of publicly available ChatGPT-3.5 conversational agents by evaluating their responses to a patient simulation indicating worsening depression and suicidality. Methodology This study evaluated ChatGPT-3.5 conversational agents on a publicly available repository specifically designed for mental health counseling. Each conversational agent was evaluated twice by a highly structured patient simulation. First, the simulation indicated escalating suicide risk based on the Patient Health Questionnaire (PHQ-9). For the second patient simulation, the escalating risk was presented in a more generalized manner not associated with an existing risk scale to assess the more generalized ability of the conversational agent to recognize suicidality. Each simulation recorded the exact point at which the conversational agent recommended human support. Then, the simulation continued until the conversational agent stopped entirely and shut down completely, insisting on human intervention. Results All 25 agents available on the public repository FlowGPT.com were evaluated. The point at which the conversational agents referred to a human occurred around the mid-point of the simulation, and definitive shutdown predominantly only happened at the highest risk levels. For the PHQ-9 simulation, the average initial referral and shutdown aligned with PHQ-9 scores of 12 (moderate depression) and 25 (severe depression). Few agents included crisis resources - only two referenced suicide hotlines. Despite the conversational agents insisting on human intervention, 22 out of 25 agents would eventually resume the dialogue if the simulation reverted to a lower risk level. Conclusions Current generative AI-based conversational agents are slow to escalate mental health risk scenarios, postponing referral to a human to potentially dangerous levels. More rigorous testing and oversight of conversational agents are needed before deployment in mental healthcare settings. Additionally, further investigation should explore if sustained engagement worsens outcomes and whether enhanced accessibility outweighs the risks of improper escalation. Advancing AI safety in mental health remains imperative as these technologies continue rapidly advancing.

Usage of unguided, guided, and blended care for depression offered in routine clinical care: Lessons learned

Introduction

Internet-delivered psychotherapy is often considered to be a promising way to extend mental healthcare services around the world. Research findings that have emerged over the past two decades have strengthened this claim. However, very little is known about the usage of internet-delivered psychotherapy in real-life circumstances.

Methods

The current study explored the real-life usage of depressiehulp.be, a publicly available online platform for depression that offers pure self-help, online guided self-help, and blended treatment for depression in Flanders, Belgium, using data collected from 2656 participants between May 2018 and May 2022.

Results

Both duration of engagement with the online platform and number of exercises completed increased with increasing levels of therapist guidance. Findings also showed a particular pattern of engagement for each of the online treatments. Overall, participants completed most exercises during the first days of treatment. However, participants using pure online self-help showed the fastest decrease of engagement over time, with most dropping out after completing a few exercises, and more than half of all participants who enrolled in the self-help programme did not even begin the programme. In both guided and blended treatment, participants tended to show higher levels of engagement with the online platform. In each treatment modality, a relatively small but notable group of participants showed high levels of engagement. There was no relationship between severity of depression and duration of engagement.

Conclusions

The current study demonstrates the importance of therapist support in online interventions and offers additional insights into how, and to what extent, online platforms are used. Future research should explore clinical impact and policy implications.

Demystifying treatment disposition patterns for psychiatrically high-risk youth referred for intensive outpatient psychiatric services: The role of demographics and telehealth

Intensive outpatient (IOP) psychiatric treatment is increasingly deployed to meet the needs of psychiatrically high-risk youth; however, documentation of treatment disposition for in-person and/or telehealth modalities following treatment referral is largely unknown. The current study examined psychiatrically high-risk youth baseline treatment disposition patterns and explored variations according to treatment modality (telehealth vs. in-person). Using archival records of 744 adolescents (Mage = 14.91, SD = 1.60) admitted to a psychiatric IOP, multinomial logistic regressions revealed that commercially insured youth fared better than non-commercially insured youth with respect to treatment completion. When treatment modality was accounted for, youth treated on telehealth were no more likely to be psychiatrically hospitalized compared to youth treated with in-person services. However, youth treated on telehealth dropped out due to excessive absences or withdrawal/refusal to a greater extent than those treated in person. Future studies should examine clinical outcomes in addition to treatment disposition patterns to further understand youth's course of treatment at intermediate level of care settings (e.g., IOP).

Integrating trauma-informed services in out-of-school time programs to mitigate the impact of community gun violence on youth mental health

Community gun violence disproportionately impacts youth in low-income urban neighborhoods. Integrating trauma-informed mental health care in community-based out-of-school time (OST) programs is an innovative method of service delivery for these youth. This article provides justification for integrating evidence-based, trauma-informed services in OST programs within communities characterized by high rates of violent crime to minimize the impact of violence exposure on youth mental health. We describe the initial feasibility of a model program, the Violence Intervention and Prevention (VIP) Initiative, implemented in a small city in southeastern Pennsylvania. Within the first six months of the VIP Initiative, 95 community residents (90% under age 18; 51% Hispanic) received intervention services, primarily through single-session and short-term weekly group intervention in OST programs, and 80% of OST youth development staff participated in at least one trauma-informed professional development training. Recommendations to enhance and expand the delivery of trauma-informed services in the novel setting of OST programs are provided.

Nurses' Perceptions of Telephone Triage in Child and Adolescent Psychiatric Services - An Enhanced Critical Incident Technique Study

In Sweden, units managed by nurses specialised in counselling and telephone triage, have been developed within the Child and Adolescent Mental Health services (CAMHS). This study has a qualitative design and illuminates the nurses' perceptions of what helps or hinders their assessments and telephone triage. The Enhanced Critical Incident Technique was utilised, eight nurses were interviewed in depth, to identify factors influencing triage. The study is the first to provide a comprehensive description of helpful and hindering factors while performing telephone triage. It illuminates telephone triage in Swedish CAMHS settings and provides insights how to enhance and implement this practice.

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study

BACKGROUND

Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap.

OBJECTIVE

We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department.

METHODS

Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time.

RESULTS

The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023.

CONCLUSIONS

SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45666.

Development of an HIV/STI and partner violence health promotion intervention for abused US Virgin Islands women

Women in the US Virgin Islands (USVI) experience intimate partner violence (IPV) and human immunodeficiency virus (HIV) at disproportionate rates compared to women on the US mainland. Women in violent relationships report experiencing controlling behaviours that decrease their ability to negotiate for sex using condoms or to prevent unwanted pregnancies. Though several evidence-based interventions exist to prevent either IPV or HIV, few address them through an integrated health promotion approach or attend to particular USVI cultural mores. This article describes the systematic development of a theory based, culturally tailored, integrated health promotion intervention that addresses IPV and HIV among USVI women experiencing abuse. The process included: (i) identifying and integrating evidence-based health promotion interventions, (ii) conducting formative research using focus groups, (iii) synthesizing focus group data to inform intervention development and (iv) developing a culturally and linguistically appropriate intervention specific to the needs and concerns of USVI women. The Empowered Sisters Project: Making Choices Reducing Risks (ESP) was developed through this research. ESP is a three-session health promotion curriculum focussed on enhancing sexual health and safety among women experiencing abuse. The ESP intervention components included promoting condom use, increasing IPV and HIV knowledge and developing a personalized safety plan. Health professionals facilitated individual intervention sessions using culturally tailored visual media and scripts. This program focussed on experiences of women living in the USVI and has implications for utility across the Caribbean diaspora.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Project Body Neutrality: Piloting a digital single-session intervention for adolescent body image and depression

OBJECTIVE

Eating disorders and depression impact youth at alarming rates, yet most adolescents do not access support. Single-session interventions (SSIs) can reach youth in need. This pilot examines the acceptability and utility of a SSI designed to help adolescents improve functionality appreciation (a component of body neutrality) by focusing on valuing one's body based on the functions it performs, regardless of appearance satisfaction.

METHOD

Pre- to post-intervention data were collected, and within-group effect sizes and 95% confidence intervals were computed, to evaluate the immediate effects of the SSI on hopelessness, functionality appreciation, and body dissatisfaction. Patterns of use, demographics, program feedback, and responses from within the SSI were collected.

RESULTS

The SSI and all questionnaires were completed by 75 adolescents (ages: 13-17 years, 74.70% White/Caucasian, 48.00% woman/girl) who reported elevated body image and mood problems. Analyses detected significant pre-post improvements in hopelessness (dav  = 0.60, 95% CI: 0.35-0.84; dz  = 0.77, 95% CI: 0.51-1.02), functionality appreciation (dav  = 0.72, 95% CI: 0.46-0.97; dz  = 0.94, 95% CI: 0.67-1.21), and body dissatisfaction (dav  = 0.61, 95% CI: 0.36-0.86; dz  = 0.76, 95% CI: 0.50-1.02). The SSI was rated as highly acceptable, with a mean overall score of 4.34/5 (SD = 0.54). Qualitative feedback suggested adolescents' endorsement of body neutrality concepts, including functionality appreciation, as personally-relevant, helpful targets for intervention.

DISCUSSION

This evaluation supports the acceptability and preliminary effectiveness of the Project Body Neutrality SSI for adolescents with body image and mood concerns.

PUBLIC SIGNIFICANCE

Results suggest the acceptability and utility of a digital, self-guided, single-session intervention-Project Body Neutrality-for adolescents experiencing co-occurring depressive symptoms and body image disturbances. Given the intervention's low cost and inherent scalability, it may be positioned to provide support to youth with limited access to traditional care.

Changing the landscape of mental health among college students: a community case study of a course on learning sustainable well-being

Our society is facing an unprecedented mental health crisis, with nearly one in two people being affected by mental health issues over their lifespan. This trend is especially noticeable among college students, who undergo significant shifts in social, familial, and academic responsibilities. Exacerbating the mental health crisis is the fact that students are facing other societal crises (e.g., climate change). And, in a reciprocal fashion, students experiencing poor mental health are less likely to feel resilient enough to tackle these other crises. In response to these colliding societal crises, we need a comprehensive solution that goes beyond the current models of college mental health services. We propose an alternative preventative mental health approach, which aims to prevent the onset of mental health concerns and build resilience in the face of colliding crises. Specifically, we argue that colleges can aid in building mental health resilience by creating for-credit courses that teach students the skills they need to be conscious, responsible, and resilient human beings. Toward this end, we created an experiential, workshop-style, 1 unit, P/NP course, entitled "Learning Sustainable well-being" (LSW), which guides students to explore, improve, and sustain their mental health. The principles taught in this course combine the wisdoms of several disciplines, including mindfulness, psychology, neuroscience, philosophy, religion, poetry, and cinema. The following community case study reflects on the journey of our "LSW initiative," starting from the creation of the course in 2014 to the current mission of scaling up the offering as part of an institution-wide LSW program. To this end, we describe the LSW course modules/content, our pedagogical approach, potential limitations, and then provide data demonstrating its efficacy in improving student well-being. As a final note, we present the challenges we have faced, and the lessons learned, while on this journey. We hope that presenting this community case study will facilitate the growing dialogue across colleges about creating (and perhaps requiring) courses like LSW in order to improve students' mental health and resilience in the context of other colliding crises.

Chatbot-assisted therapy for patients with methamphetamine use disorder: a preliminary randomized controlled trial

Background

Methamphetamine (MA) use disorder is associated with a large public health burden. Despite the therapeutic effects of psychosocial interventions based on current evidence, finding an approach to retain patients in treatment remains a real-world challenge. The rapid development of mobile health (mHealth) systems suggests the potential to provide real-time personalized care at any time and from any location, minimize barriers to treatment, maximize use, and promote the dissemination of accessible therapeutic tools in at-risk populations. Our study aimed to investigate the feasibility and effectiveness of chatbots for the treatment of MA use disorder.

Method

The inclusion criteria were (a) a diagnosis of MA use disorder as defined by the DSM-5, (b) age between 18 and 65 years, (c) no acute exacerbation of severe mental illness during the initial assessment, such as schizophrenia or bipolar I disorder, (d) willingness to participate in standard outpatient treatment for ≥ 6 months, and (e) an Android phone. Participants were randomly allocated to either a chatbot-assisted therapy via smartphone (CAT) group or a control group following simple randomization procedures (computerized random numbers) without blinding. All participants were followed up for 6 months. Treatment retention and monthly urine test results were analyzed as outcome measures. Participants' satisfaction with CAT was also assessed.

Results

In total, 50 and 49 participants were allocated to the CAT and control groups, respectively. There were no significant differences in retention time between the two treatment groups (df = 1, p = 0.099). The CAT group had fewer MA-positive urine samples than the control group (19.5% vs. 29.6%, F = 9.116, p = 0.003). The proportion of MA-positive urine samples was positively correlated with the frequency of MA use (r = 0.323, p = 0.001), severity of MA use disorder (r = 0.364, p < 0.001), and polysubstance use (r = 0.212, p = 0.035), and negatively correlated with readiness to change (r = -0.330, p = 0.001). Totally 55 participants completed the study at the 6-month follow-up and 60% reported relative satisfaction.

Conclusion

Participants in this study had favorable acceptance and generally positive outcomes, which indicates that chatbot is feasible for treating people who use MA.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a disruptive behaviour disorder involving an ongoing pattern of angry/irritable mood, argumentative/defiant behaviour and vindictiveness. Onset is typically before 8 years of age, although ODD can be diagnosed in both children and adults. This disorder is associated with substantial social and economic burden, and childhood ODD is one of the most common precursors of other mental health problems that can arise across the lifespan. The population prevalence of ODD is ~3 to 5%. A higher prevalence in males than females has been reported, particularly before adolescence. No single risk factor accounts for ODD. The development of this disorder seems to arise from the interaction of genetic and environmental factors, and mechanisms embedded in social relationships are understood to contribute to its maintenance. The treatment of ODD is often successful, and relatively brief parenting interventions produce large sized treatment effects in early childhood. Accordingly, ODD represents an important focus for research, practice and policy concerning early intervention and prevention in mental health.

Feasibility, Acceptability and Preliminary Implementation of the Cornerstone Program for Transition-Age Youth with Mental Health Conditions: A Mixed Methods Study

Transition-age youth with mental health conditions from low socio-economic backgrounds often drop out of mental health services and, as such, do not receive therapeutic doses of treatment. Cornerstone is an innovative team-based, multi-component intervention designed to address the clinical needs of this understudied population through coordination and extensive provision of services in vivo (in the community). The present study used a convergent parallel mixed-methods design. Researchers collected quantitative and qualitative data during a small developmental trial, analyzing the two data types independently and then exploring them side-by-side to evaluate feasibility, acceptability, and preliminary implementation. Semi-structured interviews and quantitative surveys were conducted with transition-age youth, clinic staff, and policy makers. Qualitative interview guides were developed using the Consolidated Framework for Implementation Research to build understanding on implementation determinants alongside feasibility and acceptability. A two-group preliminary randomized trial was conducted to assess feasibility outcomes, such as recruitment, randomization, measurement performance, and trends in pre- to post- outcomes. Using grounded theory coding techniques, transcripts were coded by multiple coders, and themes were identified on acceptability and implementation. The team recruited fifty-six transition-age youth. Randomization was used in the study and the intervention was provided without incident. Results suggest individual components with both the social worker and mentor were more acceptable to participants than group-based approaches. Thematic analyses revealed themes associated with the inner, outer, and policy contexts describing a range of critical implementation determinants. Findings suggest that Cornerstone is feasible, acceptable, and promising for transition-age youth. It represents an innovative multi-component intervention worth exploring for transition-age youth with mental health conditions in a larger efficacy trial.Trial registration: The trial was registered at ClinicalTrials.gov (NCT02696109) on 22 April 16, Protocol Record R34-MH102525-01A1, New York University, Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial.

Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mental health problems are a crucial global public health concern. Owing to their cost-effectiveness and accessibility, conversational agent interventions (CAIs) are promising in the field of mental health care.

OBJECTIVE

This study aims to present a thorough summary of the traits of CAIs available for a range of mental health problems, find evidence of efficacy, and analyze the statistically significant moderators of efficacy via a meta-analysis of randomized controlled trial.

METHODS

Web-based databases (Embase, MEDLINE, PsycINFO, CINAHL, Web of Science, and Cochrane) were systematically searched dated from the establishment of the database to October 30, 2021, and updated to May 1, 2022. Randomized controlled trials comparing CAIs with any other type of control condition in improving depressive symptoms, generalized anxiety symptoms, specific anxiety symptoms, quality of life or well-being, general distress, stress, mental disorder symptoms, psychosomatic disease symptoms, and positive and negative affect were considered eligible. This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were extracted by 2 independent reviewers, checked by a third reviewer, and pooled using both random effect models and fixed effects models. Hedges g was chosen as the effect size.

RESULTS

Of the 6900 identified records, a total of 32 studies were included, involving 6089 participants. CAIs showed statistically significant short-term effects compared with control conditions in improving depressive symptoms (g=0.29, 95% CI 0.20-0.38), generalized anxiety symptoms (g=0.29, 95% CI 0.21-0.36), specific anxiety symptoms (g=0.47, 95% CI 0.07-0.86), quality of life or well-being (g=0.27, 95% CI 0.16-0.39), general distress (g=0.33, 95% CI 0.20-0.45), stress (g=0.24, 95% CI 0.08-0.41), mental disorder symptoms (g=0.36, 95% CI 0.17-0.54), psychosomatic disease symptoms (g=0.62, 95% CI 0.14-1.11), and negative affect (g=0.28, 95% CI 0.05-0.51). However, the long-term effects of CAIs for the most mental health outcomes were not statistically significant (g=-0.04 to 0.39). Personalization and empathic response were 2 critical facilitators of efficacy. The longer duration of interaction with conversational agents was associated with the larger pooled effect sizes.

CONCLUSIONS

The findings show that CAIs are research-proven interventions that ought to be implemented more widely in mental health care. CAIs are effective and easily acceptable for those with mental health problems. The clinical application of this novel digital technology will conserve human health resources and optimize the allocation of mental health services.

TRIAL REGISTRATION

PROSPERO CRD42022350130; https://tinyurl.com/mvhk6w9p.

The impact of COVID-19 on sleep for autistic children: A systematic review

BACKGROUND

Up to 80% of children with autism experience behavioural sleep problems, predominantly relating to bedtime resistance, sleep anxiety, sleep dysregulation, and shorter duration, which are associated with increased autistic symptom expression and emotional and behavioural difficulties. Researchers predicted the COVID-19 pandemic would worsen sleep and behavioural difficulties for autistic children, due to their need for routine and certainty. This systematic review is the first to focus on delineating the role of sleep disturbance in exacerbating autistic symptoms and internalising and externalising behaviours during the pandemic.

METHOD

In this PROSPERO registered systematic review, we aggregated and synthesised findings from empirical studies from 2020 onwards that included children with autism and examined sleep outcomes, using narrative and framework synthesis due to the variety of methods and designs employed. We identified additional relevant themes through inductive thematic analysis.

RESULTS

Seventy-one studies met the search criteria, and we selected seventeen for review following screening and quality assessment. These studies reported mixed findings; with strongest support for worsening of sleep problems typically experienced by autistic children, including difficulties with sleep regulation and shorter sleep duration. Further, sleep problems were associated with increased expression of autistic characteristics.

CONCLUSIONS

Preliminary findings of worsening sleep and increased autistic characteristics for autistic children throughout the COVID-19 pandemic highlight the need for ongoing, accessible and flexible service provision during exposure to environmental stressors. We propose that behavioural sleep interventions are well suited to telehealth adaptation and play an important role in supporting families when in-person treatment for sleep problems is not possible.

My Early Relational Trust-Informed Learning (MERTIL) for Parents: A study protocol for a brief, universal, online, preventative parenting program to enhance relational health

BACKGROUND

Early relational health is a key determinant of childhood development, while relational trauma in the parent-infant dyad can instigate a cascading pattern of infant risk. Fortunately, early relational trauma is detectable and modifiable. In 2018, Australian Maternal and Child Health (MCH) nurses participated in MERTIL (My Early Relational Trauma-Informed Learning), a program to identify and prevent relational trauma. Program evaluations revealed nurses felt competent and confident to identify and respond to relational trauma; however, response capacity was inhibited by inadequate parent referral options. In response, MERTIL for Parents (My Early Relational Trust-Informed Learning) was developed, which is an online, evidence-based, self-paced parenting program that focuses on enhancing parental knowledge of relational trust and its significance for infant development. This low-cost, accessible prevention resource targets emerging relational concerns to reduce later service system engagement. The potential for universal preventative online programs that target parental and relational wellbeing remains under-explored. This paper reports on a protocol for implementing a MERTIL for Parents pilot study describing practitioners' and parents' perspectives on program feasibility and efficacy.

METHODS

This study is a mixed methods, parallel armed, uncontrolled, repeated measures design. We aim to recruit 48 Australian MCH practitioners from the states of Victoria and New South Wales. These professionals will in turn recruit 480 parents with a child aged 0-5 years. All parents will receive MERTIL for Parents, which entails a 40-minute video, tipsheets, posters, and support resources. Parent data will be obtained at three periods: pre-program, program exit, and program follow-up. Practitioner data will be collected at two periods: pre-parent recruitment and program follow-up. Data collection will occur through surveys and focus groups. Primary parent outcomes will be socioemotional assessments of program efficacy. Practitioners and parents will each report on program feasibility.

DISCUSSION

This protocol describes the feasibility and efficacy of a new online parenting program, MERTIL for Parents, with pilot field studies commencing in March 2023. We anticipate that this resource will be a valuable addition to various child and family services, for use in individual support and group work.

Accuracy of a Proactive Case Detection Tool for Internalizing and Externalizing Problems Among Children and Adolescents

PURPOSE

Lack of identification and referral of children and adolescents with mental health problems contributes to the treatment gap in low- and middle-income countries, and especially in humanitarian settings. The Community Case Detection Tool (CCDT) is developed to improve community-based detection and increase help-seeking among children and adolescents in need of mental health care. The CCDT uses brief, easily understood pictorial vignettes that represent common symptoms of childhood internalizing and externalizing problems. The tool is developed for gatekeepers to support proactive detection of children in need of mental health care and to subsequently encourage help-seeking. This study evaluates the accuracy of the CCDT in detecting children and adolescents aged 6-18 years with significant mental health care needs in a conflict-affected setting: the occupied Palestinian territory.

METHODS

Teachers and community workers were trained to use the CCDT. Children detected using the tool were invited for a structured clinical interview with a psychologist using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version, as well as the Strengths and Difficulties Questionnaire, to test the accuracy of CCDT-based detection.

RESULTS

Our sample consists of 52 children positively detected as matching with one of the vignettes. Approximately three of four detected children were indicated for psychological treatment based on the clinical interview (positive predictive value = .769), and 64.6% returned 'borderline' or 'abnormal' total difficulty scores on the Strengths and Difficulties Questionnaire.

CONCLUSIONS

The CCDT offers a promising low-cost solution to mitigate underdetection of mental health problems in challenging settings.

Young Adult Mental Health Beyond the COVID-19 Era: Can Enlightened Policy Promote Long-Term Change?

The status of mental health for adolescents and young adults has aptly been termed a "crisis" across research, clinical, and policy quarters. Arguably, the status quo provision of mental health services for adolescents and young adults is neither acceptable nor salvageable in its current form. Instead, only a wholesale policy transformation of mental health sciences can address crises of this scope. Pandemic-related impacts on mental health, particularly among young adults, have clearly exposed the need for the mental healthcare field to develop a set of transformative priorities to achieve long overdue, systemic changes: (1) frequent mental health tracking, (2) increased access to mental health care, (3) working with and within communities, (4) collaboration across disciplines and stakeholders, (5) prevention-focused emphasis, (6) use of dimensional descriptions over categorical pronouncements, and (7) addressing systemic inequities. The pandemic required changes in mental healthcare that can and should be the beginning of long-needed reform, calling upon all mental health care disciplines to embrace innovation and relinquish outdated traditions.

A Digital Single-Session Intervention Platform for Youth Mental Health: Cultural Adaptation, Evaluation, and Dissemination

BACKGROUND

Despite the proliferation of evidence-based digital mental health programs for young people, their low uptake and inconsistent implementation preclude them from benefiting youths at scale. Identifying effective implementation strategies for evidence-based supports is especially critical in regions where treatment access is lowest owing to mental health provider shortages.

OBJECTIVE

The goal of this academic-community partnership, funded by the City of San Antonio Metropolitan Health District, was to culturally adapt, disseminate, and gauge the acceptability and utility of an evidence-based digital mental health platform-Project Youth Empowerment and Support (YES)-among English- and Spanish-speaking youths living in south Texas.

METHODS

Project YES is an open-access, anonymous platform containing 3 evidence-based, self-guided interventions for youth mental health. Project YES was culturally adapted via focus groups and co-design sessions with San Antonio youths with lived experience of depression and anxiety; translated into Spanish; and disseminated throughout San Antonio, Texas, via community and school partnerships.

RESULTS

During the project period (April 2021 to December 2021), 1801 San Antonio youths began and 894 (49.64%) of them completed a 30-minute, single-session intervention within Project YES (aged 11-17 years; n=718, 39.87% male; n=961, 53.36% female; and n=3, 0.17% intersex; n=1477, 82.01% Hispanic; n=77, 4.28% non-Hispanic White; n=113, 6.27% Black; n=28, 1.55% Asian; and n=93, 5.16% other). This completion rate (49.64%) surpassed those previously observed for Project YES (eg, 34% when disseminated via social media). San Antonio youths rated Project YES as highly acceptable across all metrics, both in English and Spanish. In addition, the youths who completed Project YES-ENGLISH reported significant improvements in hopelessness (Cohen d=0.33; P<001), self-hate (Cohen d=0.27; P<001), and perceived agency (Cohen d=0.25; P<001) from before to after the intervention, and the youths who completed Project YES-SPANISH reported significant improvements in self-hate (Cohen d=0.37; P=.049) from before to after the intervention.

CONCLUSIONS

The results indicate that Project YES-an open-access, free, and anonymous web-based single-session intervention platform-is an acceptable, accessible, and applicable mental health support for English- and Spanish-speaking San Antonio youths.

Internet-delivered psychological treatment as an add-on to treatment as usual for common mental disorders: A systematic review with meta-analysis of randomized trials

BACKGROUND

Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS

The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS

The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS

TAU varied across studies and was often insufficiently described.

CONCLUSIONS

iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

Stepping Together in Stepped Care Trauma-Focused Cognitive Behavioral Therapy: Case Report of Core Components

New service delivery systems are needed to expand the reach of evidence-based practices for childhood trauma. Cognitive behavioral therapy is an effective approach for treating -childhood trauma, yet treatment barriers remain. Stepped care models that incorporate parent-led -treatment with therapist assistance may be one approach to improve access. This case study highlights the core components of a parent-led therapist-assisted treatment called Stepping Together that serves as a Step 1 treatment within a stepped care model. The components and structure of Stepping Together are described, along with excerpts from therapy sessions to illustrate the therapist's implementation of the model. Results of the case, in which improvements occurred, are presented. Stepping Together, a parent-led therapist-assisted first-line treatment within stepped care trauma-focused cognitive behavioral therapy, may be an effective treatment for some children after trauma and their caregivers, although more research is needed.

Magis - A magical adventure: Using a mobile game to deliver an ACT intervention for elementary schoolchildren in classroom settings

Studies of the effects of the COVID-19 pandemic have shown that this health emergency has affected especially young people. Supporting the well-being of children is thus particularly urgent. However, the high prevalence of ill-being among children requires novel approaches to providing help. Health care resources are limited, and many children did not receive support even before the pandemic. The current study presents a novel approach to delivering brief interventions for school-aged children. A mobile game based on acceptance and commitment therapy was used to increase psychological flexibility and well-being among 10 to 12-year-old schoolchildren. A sample of 106 students played the game in four weekly sessions as part of normal teaching practice in school. The effectiveness of the brief game intervention was examined as a universal intervention among the whole sample and among subgroups created on the basis of baseline psychological flexibility (i.e., based on the need for an intervention). The results show that higher psychological flexibility was associated with less emotional and behavioral problems, higher health-related quality of life, mood, and school satisfaction, and less loneliness (r = 0.46-0.63). While a significant effect was not detected in the whole sample, the subsample of children with initially high psychological inflexibility benefitted from participating in the intervention (Cohen's d = 0.35). These preliminary findings suggest that the brief game-based intervention can increase psychological flexibility among children when the need for an intervention is considered. Further research is necessary to examine the stability of improvements in psychological flexibility.

Examining concurrent validity and item selection of the Session Wants and Needs Outcome Measure (SWAN-OM) in a children and young people web-based therapy service

BACKGROUND

Single-session mental health interventions are frequently attended by children and young people (CYP) in both web-based and face-to-face therapy settings. The Session "Wants" and "Needs" Outcome Measure (SWAN-OM) is an instrument developed in a web-based therapy service to overcome the challenges of collecting outcomes and experiences of single-session therapies (SSTs). It provides pre-defined goals for the session, selected by the young person prior to the intervention, on which progress toward achievement is scored at the end of the session.

OBJECTIVE

The objective of this study was to evaluate the instrument's psychometric properties, including concurrent validity against three other frequently used outcome and experience measures, at a web-based and text-based mental health service.

METHODS

The SWAN-OM was administered for a period of 6 months to 1,401 CYP (aged 10-32 years; 79.3% white; 77.59% female) accessing SST on a web-based service. Item correlations with comparator measures and hierarchical logistic regressions to predict item selection were calculated for concurrent validity and psychometric exploration.

RESULTS

The most frequently selected items were "Feel better" (N = 431; 11.61%) and "Find ways I can help myself" (N = 411; 11.07%); unpopular items were "Feel safe in my relationships" (N = 53; 1.43%) and "Learn the steps to achieve something I want" (N = 58; 1.56%). The SWAN-OM was significantly correlated with the Experience of Service Questionnaire, particularly the item "Feel better" [rs₍₁₀₉₎ = 0.48, p < 0.001], the Youth Counseling Impact Scale, particularly the item "Learn the steps to achieve something I want" [rs₍₂₂₎ = 0.76, p < 0.001], and the Positive and Negative Affect Schedule, particularly the items "Learn how to feel better" [rs₍₂₂₎ = 0.72, p < 0.001] and "Explore how I feel" [rs₍₇₀₎ = -0.44, p < 0.001].

CONCLUSION

The SWAN-OM demonstrates good concurrent validity with common measures of outcome and experience. Analysis suggests that lesser-endorsed items may be removed in future iterations of the measure to improve functionality. Future research is required to explore SWAN-OM's potential to measure meaningful change in a range of therapeutic settings.

Seven reasons why binary diagnostic categories should be replaced with empirically sounder and less stigmatizing dimensions

Background

An ongoing positive revolution advocates a new approach to the individual differences in human emotions, cognitions, and behavior that cause distress and impair functioning. This revolution endorses the long-proposed, but still unrealized rejection of the medical model, which attributes psychological problems to a sick brain or mind. In addition, it advocates replacing the binary diagnoses used in ICD and DSM, which assume a clear discontinuity between "normal" and "abnormal" functioning, with continuous dimensions of psychological problems.

Method

Selective literature review.

Results and Discussion

Seven strong reasons are provided for adopting a dimensional approach.

"Pain, Stress, and Emotions": Uncontrolled trial of a single-session, telehealth, emotional awareness and expression therapy class for patients with chronic pain

Objectives

Trauma- and emotion-focused chronic pain interventions, particularly Emotional Awareness and Expression Therapy (EAET), show much promise for reducing pain and improving functioning. We developed a novel, single-session, telehealth-delivered EAET class ("Pain, Stress, and Emotions"; PSE) and tested it on adults with chronic pain of mixed etiology.

Methods

After an initial developmental phase, we conducted an uncontrolled trial, providing PSE to 74 individuals with chronic pain (63.5% female; 64.9% White; 60.8% with pain duration >5 years) in four class administrations. Participants completed self-report measures (primary outcomes: pain intensity and pain interference) at baseline and multiple follow-ups to 12 weeks. Linear mixed-models examined changes over time, and effect sizes were calculated on change from baseline to 4-week (primary endpoint) and 12-week follow-ups. The trial was registered with clinicaltrials.gov (NCT05014126).

Results

Participants reported high satisfaction with the PSE class. Pain intensity showed a significant, medium reduction across time (p < .001; d = 0.60 at 4 weeks); one-quarter of participants had clinically meaningful pain reduction (≥30%). Pain interference had a large reduction (p < .001; d = 0.74). There were significant but smaller improvements in most secondary outcomes (ds = 0.15 to 0.55; ps < .01). Effects were generally maintained or increased at 12-week follow-up. Higher education and baseline ambivalence over emotional expression predicted greater pain reductions.

Conclusions

People taking this EAET class had reduced pain severity and interference and improvements in other pain-related outcomes. The single-session, telehealth class holds promise as an easily delivered, efficient, and potentially impactful intervention for some patients with chronic pain, although controlled trials are needed.

Traumatic stress, body shame, and internalized weight stigma as mediators of change in disordered eating: a single-arm pilot study of the Body Trust® framework

To enhance access to evidence-based treatment it is increasingly important to evaluate scalable virtual programs that support the needs of those struggling with disordered eating. This study described a scientifically grounded, trauma-informed framework known as Body Trust,® and aimed to pilot test the preliminary effectiveness and mechanisms of change in a Body Trust® program to improve disordered eating. Using quality outcomes data, we examined 70 mostly white (87%) female-identifying (97%) individuals enrolled in a 6-module online program based in the Body Trust® framework (M_age = 45.5 ±10.9; M_BMI = 33.7 ±8.0). Putative mediators included traumatic stress, internalized weight stigma, and body shame. Outcomes were objective and subjective binge episodes, overvaluation of weight and shape, and eating concerns. Generalized estimating equations were applied to determine pre-to-post changes. We applied Montoya's MEMORE macro, the joint-significance test, and calculated 95% Monte Carlo confidence intervals to assess mediation. Significant pre-to-post improvements with medium to large effect sizes were detected for all outcomes and mediators (ps<.008). All hypothesized mechanisms supported mediation. Using the Body Trust® framework shows early promise for alleviating disordered eating symptoms through targeting traumatic stress, body shame, and internalized weight stigma. Given the program's use of mindfulness techniques, future research should test target mechanisms like interoception.

Online parent training platform for complementary treatment of disruptive behavior disorders in attention deficit hyperactivity disorder: A randomized controlled trial protocol

Background

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with a diversity of impairments and Oppositional Defiant Disorder (ODD) is a very frequent comorbidity. Parent Training, as an evidence-based intervention, seems effective in reducing externalizing/disruptive behaviors, possibly leading to a better prognosis. This clinical trial aims to evaluate the effectiveness of an online parent training model as a complementary treatment for ADHD and ODD.

Methods

Patients and their families will be screened upon their entry into the Research Center of Impulsivity and Attention (NITIDA) at UFMG—Brazil. Ninety families whose children are male, between 6–12 years old, and have significant externalizing symptoms and whose primary caregiver have complete high school education will be invited to participate. Families will be randomized (1:1) into 03 groups: 1) standard care; 2) standard care + face-to-face parent training; 3) standard care + online parent training. Interventions are analogous, differing only in delivery format. In the face-to-face format, the intervention will be conducted by a specialized therapist and the online format will be carried out through a platform. There will be six sessions/modules, arranged on a weekly basis. Measures of externalizing symptoms, parental and children quality of life, parental stress and parenting style will be collected at baseline and after the intervention.

Discussion

This clinical trial intends to verify the effects of a new, online, model of an evidence-based intervention, which would allow a wider access in the Brazilian context.

Trial registration

Registered on Brazilian Registry of Clinical Trials (ReBEC). Number: RBR-6cvc85. July 24^th (2020) 05:35 pm.

A comic-based body image intervention for adolescents in semi-rural Indian schools: Study protocol for a randomized controlled trial

Adolescents in India experience body dissatisfaction, however, empirically supported interventions are lacking. This paper describes the protocol for the development, acceptability testing, and cluster randomized controlled trial (RCT) of a six-session comic-based intervention, which aims to improve body image and related outcomes among adolescents in semi-rural Indian schools. If found to be acceptable and effective, UNICEF will disseminate the intervention across schools in eight states of India. The acceptability study will be conducted with 24 students in Classes 6-8 (age 11-14) and nine teachers from Hindi-medium government schools using interviews and focus groups. The subsequent RCT will be conducted with 2400 students, with schools randomized to either the comic-based intervention or lessons-as-usual (control) groups. The primary outcome is body esteem, and secondary outcomes are disordered eating, appearance ideal internalization, body-image-related life disengagement, self-esteem, negative affect, and positive affect. Additional exploratory outcome measures are skin colour dissatisfaction, body hair dissatisfaction, appearance-based teasing, and endorsement of traditional gender roles. These outcomes will be examined at three timepoints: baseline (T1), 1 week-post-intervention (T2), and 12-weeks follow-up (T3). Analyses will compare outcomes in the intervention with the control group. This will be the first study to evaluate a body image intervention for adolescents in semi-rural Indian schools.

Enhancing primary care psychology services with assistant psychologists in Ireland: An evaluation of output, throughput and stakeholder satisfaction

Primary care mental health services need to expand to assist the increased number of people reporting mild to moderate mental health difficulties. In Ireland, the primary care mental health service has been recently enhanced through the employment of Assistant Psychologists (AP) in primary care psychology. This paper provides an early and brief evaluation of the impact of the AP-enhanced model through a tripartite approach to evaluation which utilises measures of throughput, output and stakeholder satisfaction. We use data from two sources; Health service key performance indicators, and a routinely gathered minimal dataset of client measures. Results indicate that the numbers of clients seen in the period rose by 16%, that AP-delivered treatments are beneficial for clients with mild to moderate mental health difficulties, and more than 80% of clients reported being 'totally satisfied' with the care received. The data provide early evidence that the AP model is beneficial in meeting clients' needs across a range of presentations within the service admission criteria, and that the AP-enhanced model may offer a satisfactory solution to primary care needs. However, further data collection is required, and additional stakeholder input is necessary for a complete evaluation of the assistant psychologist model in primary care.

Understanding the Benefits of Brief Classroom-Based Physical Activity Interventions on Primary School-Aged Children's Enjoyment and Subjective Wellbeing: A Systematic Review

BACKGROUND

Engaging in classroom-based physical activity (PA) breaks may help increase children's subjective wellbeing and enjoyment of PA, important precursors for children to remain engaged in PA. We conducted a systematic review to investigate the effect of brief classroom-based PA interventions on primary school children's subjective wellbeing and enjoyment of PA.

METHODS

Databases were reviewed between the earliest date of records and April 2020. Eligibility criteria included peer-reviewed empirical quantitative or mixed methods studies reporting enjoyment of PA or wellbeing outcomes of participating in a brief classroom-based PA program. Fifteen papers were included. Interventions supported 7022 child participants enrolled at baseline and 6286 children analyzed in interventions across 148 schools.

RESULTS

Thirteen studies examined the effect of brief classroom-based PA interventions on subjective wellbeing. Four found a significant positive effect for children in the intervention group (specifically for children's self-efficacy in learning with video exercises, quality of life, and self-confidence). Eight studies examined the effect of brief classroom-based PA interventions on enjoyment of PA. Five studies reported a positive effect for children in the intervention group and only 1 study found a negative effect for 1 grade level of children in the intervention group. The remaining studies with wellbeing and/or enjoyment outcomes reported no significant effect.

CONCLUSIONS

Findings from these studies indicate that the integration of brief PA breaks may support PA enjoyment and specific self-beliefs and quality of life perceptions that contribute to children's subjective wellbeing. However, more research is needed to confirm this effect.

"Will it Work as Well on Zoom?" A Natural Experiment During the Covid-19 Pandemic of Delivering Parenting Groups Via Video Conferencing or in Person

While rates of child maltreatment increased during the Covid-19-pandemic, face-to-face interventions to support families got difficult to carry out due to restrictions. Meanwhile, many services do not have access to parenting programs designed for digital or remote delivery. A solution employed by some services was to use video conferencing (VC) to deliver their regular parenting programs. This study examined the effectiveness of the universal group-based parenting program ABC offered through VC instead of on-site meetings during the pandemic. Pre and post measurements were collected from 469 parents participating in either 1) ABC with VC meetings only, 2) on-site meetings only, or 3) blended - a combination of VC and on-site sessions. In addition, 74 group leaders completed a survey about their experiences of VC groups. Analyses showed general improvements in parent practices and child conduct over time, but no differences in effectiveness depending on the format of the parent group (VC, blended, or on-site). Qualitative analyses of group leaders' experiences revealed four key-themes pertaining to both challenges (e.g., concerns about parents' ability to benefit and learn parenting skills) and benefits (e.g., reaching parents who would not have been able to attend physical meetings) of VC groups. Overall, this study showed no significant differences in outcomes between the VC, blended, or on-site format of delivery. There are however limitations of this trial, and results should be considered preliminary. Effectiveness and potential negative consequences of replacing interventions intended to be delivered on-site with VC alternatives need to be further investigated in future trials.

Stepped Care Versus Standard Care for Children After Trauma: A Randomized Non-Inferiority Clinical Trial

OBJECTIVE

Trauma-focused cognitive-behavioral therapy (TF-CBT) is an evidence-based therapist-led treatment for children after trauma. Parents often experience barriers to treatment engagement, including cost. Stepped care TF-CBT (SC-TF-CBT) was developed as an alternative delivery system. Step One is a parent-led therapist-assisted treatment. Step Two provides therapist-led TF-CBT for children who did not benefit from Step One and require more intensive treatment. This study compared SC-TF-CBT to standard TF-CBT in a community-based non-inferiority trial.

METHOD

A total of 183 children (aged 4-12 years) experiencing posttraumatic stress symptoms (PTSS) and their caregivers were randomly assigned to SC-TF-CBT or standard TF-CBT within 6 community clinics. Assessments occurred at baseline, mid- and posttreatment, and 6 and 12 months. Primary outcomes included PTSS and impairment. Secondary outcomes included severity, diagnostic status, remission, and response. Treatment cost, acceptability, and satisfaction were measured. Difference and non-inferiority tests were applied.

RESULTS

SC-TF-CBT participants changed at rates comparable to participants in TF-CBT for primary and secondary measures. SC-TF-CBT was non-inferior to TF-CBT for PTSS, impairment, and severity at all time points except for impairment at the 6-month assessment. Attrition did not differ between treatment arms (132 participants were completers). Baseline treatment acceptability was lower for SC-TF-CBT parents, although there was no difference in expected treatment improvements or treatment satisfaction at posttreatment. Based on regression estimates, total costs were 38.4% lower for SC-TF-CBT compared to TF-CBT, whereas recurring costs were 53.7% lower.

CONCLUSION

Stepped Care TF-CBT provides an alternative way to deliver treatment for some children and parents, with reduced cost for providers and parents.

CLINICAL TRIAL REGISTRATION INFORMATION

Stepped Care for Children after Trauma: Optimizing Treatment; https://clinicaltrials.gov; NCT02537678.

Single-Session Interventions Embedded Within Tumblr: Acceptability, Feasibility, and Utility Study

Background

Existing mental health treatments are insufficient for addressing mental health needs at scale, particularly for teenagers, who now seek mental health information and support on the web. Single-session interventions (SSIs) may be particularly well suited for dissemination as embedded web-based support options that are easily accessible on popular social platforms.

Objective

We aimed to evaluate the acceptability and effectiveness of three SSIs, each with a duration of 5 to 8 minutes (Project Action Brings Change, Project Stop Adolescent Violence Everywhere, and REFRAME)—embedded as Koko minicourses on Tumblr—to improve three key mental health outcomes: hopelessness, self-hate, and the desire to stop self-harm behavior.

Methods

We used quantitative data (ie, star ratings and SSI completion rates) to evaluate acceptability and short-term utility of all 3 SSIs. Paired 2-tailed t tests were used to assess changes in hopelessness, self-hate, and the desire to stop future self-harm from before to after the SSI. Where demographic information was available, the analyses were restricted to teenagers (13-19 years). Examples of positive and negative qualitative user feedback (ie, written text responses) were provided for each program.

Results

The SSIs were completed 6179 times between March 2021 and February 2022. All 3 SSIs generated high star ratings (>4 out of 5 stars), with high completion rates (approximately 25%-57%) relative to real-world completion rates among other digital self-help interventions. Paired 2-tailed t tests detected significant pre-post reductions in hopelessness for those who completed Project Action Brings Change (P<.001, Cohen d_z=−0.81, 95% CI −0.85 to −0.77) and REFRAME (P<.001, Cohen d_z=−0.88, 95% CI −0.96 to −0.80). Self-hate significantly decreased (P<.001, Cohen d_z=−0.67, 95% CI −0.74 to −0.60), and the desire to stop self-harm significantly increased (P<.001, Cohen d_z=0.40, 95% CI 0.33 to 0.47]) from before to after the completion of Project Stop Adolescent Violence Everywhere. The results remained consistent across sensitivity analyses and after correcting for multiple tests. Examples of positive and negative qualitative user feedback point toward future directions for SSI research.

Conclusions

Very brief SSIs, when embedded within popular social platforms, are one promising and acceptable method for providing free, scalable, and potentially helpful mental health support on the web. Considering the unique barriers to mental health treatment access that many teenagers face, this approach may be especially useful for teenagers without access to other mental health supports.

Efficacy of interventions for suicide and self-injury in children and adolescents: a meta-analysis

Despite increased numbers of children and adolescents seeking and receiving mental health treatment, rates of self-injurious thoughts and behaviors (SITBs) in youth are rising. In the hopes of aiding ongoing efforts to alleviate the burden of SITBs in this vulnerable population, the present study summarizes current knowledge on the efficacy of SITB interventions in children and adolescents. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing treatment effects on SITBs in child and adolescent populations. A total of 112 articles comprising 558 effect sizes were included in analyses. Nearly all interventions produced nonsignificant reductions in SITBs. For binary SITB outcomes, a nonsignificant treatment effect was detected, with an RR of 1.06 (95% CIs [0.99, 1.14]). For continuous SITB outcomes, analyses also yielded a nonsignificant treatment effect (g = - 0.04 [- 0.12, 0.05]). These patterns were largely consistent across SITB outcomes, regardless of intervention type, treatment components, sample and study characteristics, and publication year. Our findings highlight opportunities for improving SITB intervention development and implementation in child and adolescent populations. The most efficacious interventions are likely to directly target the causes of SITBs; therefore, future research is needed to identify the causal processes underlying the onset and maintenance of SITBs in youth.

Impact of a peer-led, community-based parenting programme delivered at a national scale: an uncontrolled cohort design with benchmarking

Background

Childhood behavioural problems are the most common mental health disorder worldwide and represent a major public health concern, particularly in socially disadvantaged communities. Treatment barriers mean that up to 70% of children do not receive recommended parenting interventions. Innovative approaches, including evidence-based peer-led models, such as Empowering Parents Empowering Communities’ (EPEC) Being a Parent (BAP) programme, have the potential to reduce childhood difficulties and improve parenting if replicable and successfully delivered at scale.

Method

This real-world quasi-experimental study, with embedded RCT benchmarking, examined the population reach, attendance, acceptability and outcomes of 128 BAP groups (n = 930 parents) delivered by 15 newly established sites participating in a UK EPEC scaling programme.

Results

Scaling programme (SP) sites successfully reached parents living in areas of greater social deprivation (n = 476, 75.3%), experiencing significant disadvantage (45.0% left school by 16; 39.9% lived in rental accommodation; 36.9% lone parents). The only benchmarked demographic difference was ethnicity, reflecting the greater proportion of White British parents living in scaling site areas (SP 67.9%; RCT 22.4%). Benchmark comparisons showed scaling sites’ parent group leaders achieved similar levels of satisfaction. Scaling site parent participants reported substantial levels of improvement in child concerns (ES 0.6), parenting (ES 0.9), parenting goals (ES 1.2) and parent wellbeing (ES 0.6) that were of similar magnitude to RCT benchmarked results. Though large, parents reported lower levels of parenting knowledge and confidence acquisition compared with the RCT benchmark.

Conclusion

Despite common methodological limitations associated with real-world scaling evaluations, findings suggest that this peer-led, community-based, parenting approach may be capable of successful replication at scale and may have considerable potential to improve child and parenting difficulties, particularly for socially disadvantaged populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13691-y.