What Works for Whom in School-Based Anti-bullying Interventions? An Individual Participant Data Meta-analysis

The prevalence of bullying worldwide is high (UNESCO, 2018). Over the past decades, many anti-bullying interventions have been developed to remediate this problem. However, we lack insight into for whom these interventions work and what individual intervention components drive the total intervention effects. We conducted a large-scale individual participant data (IPD) meta-analysis using data from 39,793 children and adolescents aged five to 20 years (Mage = 12.58, SD = 2.34) who had participated in quasi-experimental or randomized controlled trials of school-based anti-bullying interventions (i.e., 10 studies testing nine interventions). Multilevel logistic regression analyses showed that anti-bullying interventions significantly reduced self-reported victimization (d =  - 0.14) and bullying perpetration (d =  - 0.07). Anti-bullying interventions more strongly reduced bullying perpetration in younger participants (i.e., under age 12) and victimization for youth who were more heavily victimized before the intervention. We did not find evidence to show that the inclusion of specific intervention components was related to higher overall intervention effects, except for an iatrogenic effect of non-punitive disciplinary methods-which was strongest for girls. Exploratory analyses suggested that school assemblies and playground supervision may have harmful effects for some, increasing bullying perpetration in youth who already bullied frequently at baseline. In conclusion, school-based anti-bullying interventions are generally effective and work especially well for younger children and youth who are most heavily victimized. Further tailoring of interventions may be necessary to more effectively meet the needs and strengths of specific subgroups of children and adolescents.

Does affirming children's autonomy and prosocial intentions help? A microtrial into intervention component effects to improve psychosocial behavior

Prior research has related children's prosocial behavior to overall well-being, and stimulating prosocial behavior is the aim of many social-emotional skills interventions. This study assessed if affirming children's autonomy stimulates their psychosocial behavior. We conducted a three-arm microtrial with four repeated measures to assess if a social-emotional skills intervention with an autonomy affirmation component had an additive effect on children's behavior as compared to a "regular" intervention focused exclusively on teaching social-emotional skills and a no-treatment control condition. Our sample consisted of 779 children in Grades 4-6 (M_age = 10.61, SD = 0.93). Findings from latent change modeling demonstrated that the social-emotional skills intervention with an autonomy affirmation component yielded superior effects as compared to the "regular" intervention and the no-treatment control condition on the improvement of internalizing and externalizing problem behavior in the three-month period after the intervention. The intervention with autonomy affirmation did not yield superior effects on prosociality and social skills, self-efficacy, and self-esteem or self-perceived competence. The absence of these effects may be attributed to the dosage of the interventions implemented-the affirmation of children's autonomy may require more than four sessions to sort observable effects. Overall, however, the findings of this study provide an initial suggestion that it may be beneficial to affirm children's autonomy and prosocial intentions when enhancing children's behavior.

Effects of Implementing Multiple Components in a School-Wide Antibullying Program: A Randomized Controlled Trial in Elementary Schools

This study investigates the effectiveness of the PRIMA antibullying program for elementary education using a cluster-randomized trial with two experimental conditions (with and without student lessons) and a control group. Students of 31 schools participated in the study (N = 3,135; M_age  = 10 years). Multilevel regression analyses demonstrated positive effects of the program on peer-reported victimization and reinforcing behavior. Implementing multiple program components was related to stronger program effects. The results provide partial experimental evidence for the beneficial effects of combining student lessons and teacher training in antibullying programs. Future experimental research is needed to investigate other approaches that reduce not only peer-reported victimization, but also self-perceived bullying and victimization.

A Social Gradient in the Effects of the Skills for Life Program on Self-Efficacy and Mental Wellbeing of Adolescent Students

BACKGROUND

The goal of the current study was to evaluate the effects of the Social Emotional Learning program Skills 4 Life on mental health and its risk factors self-esteem, self-efficacy, and social interaction skills in students of secondary schools.

METHODS

A cluster randomized controlled study was conducted, including 38 schools (66 classes; grades 7 to 9) for secondary education, with a 1 year and 20 months follow-up (teachers and students reports).

RESULTS

The intervention was effective in improving self-efficacy, depressive symptoms, and teacher-reported psychological problem behavior, all after 20 months. Stratified analyses showed effects in mainly lower educational level students.

CONCLUSION

The Skills 4 Life curriculum is effective in improving the mental health and self-efficacy among adolescents, especially for adolescents from lower educational level, a group that is most prone to ill mental health.

Process Evaluation of 'Learn Young, Learn Fair'

This article describes the process evaluation of a stress management program called `Learn Young, Learn Fair' for 5th and 6th graders. Studies, reviews and meta-analyses of prevention programs report that a common limitation in studies is the restricted documentation of process factors that contribute to the success of interventions. Program implementation is such a factor and findings indicate that the quality of implementation significantly affects outcomes. It is associated with Type III error: no effect is established because the program itself is inadequately designed or delivered. The potential role for school psychologists in process evaluation is discussed, and the great deal Intervention Mapping has to offer in this respect. A questionnaire for both teachers and pupils was developed, with items formulated to assess implementation and to investigate whether teachers and pupils valued the program. The latter would give an indication of future adoption and implementation in the field. Implementation was divided into completeness and fidelity. Completeness for the main parts of the program, the lessons and homework assignments, was good (98.5 and 95.8 percent respectively). Completeness for the auxiliary components, the booster sessions and the daily practice exercises, was moderate (62.2 and 69.3 percent respectively). Fidelity was good; mostly the teacher implemented the lessons, almost all items were discussed, and the manual was quite strictly followed (94, 98 and 95 percent respectively). Implementation of the program was of good quality. The program was delivered as intended. Effect evaluation will not be threatened by a Type III error. The results of this study favoured the feasibility of program implementation. It is stated that school psychologists can use the findings as a criterion for program selection. In that case it will be an example of the process of enlarging the potential role of school psychology in process evaluation of mental health interventions for schools.

Effects of the Dutch Skills for Life program on the health behavior, bullying, and suicidal ideation of secondary school students

Purpose

– The purpose of this paper is to evaluate the effects of the Dutch “Skills for Life” programme on students’ health behaviours, bullying behaviour and suicidal ideation.

Design/methodology/approach

– The effectiveness of the “Skills for Life” programme on health behaviour outcomes was evaluated at three points in time in using a cluster randomized controlled study design with a follow-up of 20 months. In total, 27 schools and 1,394 students were included.

Findings

– The programme was judged to be well implemented in just under half of cases. The outcome results for the experimental group (EG) compared with controls present a complex picture at the three different time points used for evaluation. There was a clearly positive effect on levels of alcohol consumption and a clearly negative effect on smoking across time. There was a mixed picture over time for suicide ideation and for bullying including sexual bullying (although the prevalence rates for bullying were low and thus results should be treated with caution). There were generally more positive impacts on students with lower educational levels including less suicidal ideation and less bullying.

Research limitations/implications

– Limitations were the dropping out of several schools during the study and the low level of fidelity of the curriculum. Social emotional learning (SEL) programs can be part of a health promoting school framework but should be more tailored to disadvantaged school populations.

Originality/value

– The findings indicate that students with a less optimal starting position, when it comes to health related behaviours, benefit most from a SEL programme. This indicates that schools with disadvantaged school populations could benefit most from a Health Promoting School approach.

Facilitators and barriers to the successful implementation of a protocol to detect child abuse based on parental characteristics

To determine the critical facilitating and impeding factors underlying successful implementation of a method to detect child abuse based on parental rather than child characteristics known as the Hague Protocol. The original implementation region of the protocol (The Hague) was compared to a new implementation region (Friesland), using analysis of referrals, focus group interviews (n=6) at the Emergency departments (ED) and at the Reporting Centers for Child abuse and Neglect (RCCAN) as well as questionnaires (n=76) at the EDs. Implementation of the Hague Protocol substantially increased the number of referrals to the RCCAN in both regions. In Friesland, the new implementation region, the number of referrals increased from 2 out of 92,464 patients (three per 100,000) to 108 out of 167,037 patients (62 per 100,000). However in Friesland, child abuse was confirmed in a substantially lower percentage of cases relative to the initial implementation region (62% vs. 91%, respectively). Follow-up analyses suggest that this lower positive predictive value may be due to the lack of training for RCCAN professionals concerning the Hague Protocol. The focus group interviews and questionnaires point to time limitations as the main impediment for implementation, whereas an implementation coach has been mentioned as the most important facilitating factor for success. The Hague Protocol can be used to detect child abuse beyond the initial implementation region. However, training is essential in order to assure a consistent evaluation by the RCCAN.

Detecting child abuse based on parental characteristics: does the Hague Protocol cause parents to avoid the emergency department?

OBJECTIVES

The Hague Protocol is used by professionals at the adult Emergency Departments (ED) in The Netherlands to detect child abuse based on three parental characteristics: (1) domestic violence, (2) substance abuse or (3) suicide attempt or self-harm. After detection, a referral is made to the Reporting Center for Child Abuse and Neglect (RCCAN). This study investigates whether implementing this Protocol will lead parents to avoid medical care.

METHOD

We compared the number of patients (for whom the Protocol applied) who attended the ED prior to implementation with those attending after implementation. We conducted telephone interviews (n = 14) with parents whose children were referred to the RCCAN to investigate their experience with the procedure.

RESULTS

We found no decline in the number of patients, included in the Protocol, visiting the ED during the 4 year implementation period (2008-2011). Most parents (n = 10 of the 14 interviewed) were positive and stated that they would, if necessary, re-attend the ED with the same complaints in the future.

CONCLUSION

ED nurses and doctors referring children based on parental characteristics do not have to fear losing these families as patients.

Mainstream and special school attendance among a Dutch cohort of children with Down Syndrome

Object

To determine the level of mainstream education in a nationwide cohort of adolescents with Down Syndrome (DS), and to find characteristics related to mainstream or special school attendance.

Method

Dutch children with DS born in 1992, 1993 or 1994, were assessed when 16–19 years old. Parents scored school enrolment between the age of 4–18 years, general characteristics and the levels of intellectual disability using the Dutch Social Competence Rating Scale. Associations between disability and years in mainstream school were assessed by ordinal logistic regression, adjusting for sex and parental education.

Results

We collected data from 170 boys and 152 girls (response 63%); mean age 18.3 years (ranges 16.8–19.9). Intellectual disability was mostly moderate (43%). Most children (74%) entered mainstream education between 4 and 6 years of age. At 13 years 17% was in mainstream school and 7% stayed in up to 16 years. From the age of 8 years onwards the majority was in special education, while 6% never attended school. Girls were more often in mainstream school and stayed in longer. Level of disability was significantly associated with number of years in mainstream education.

Conclusion

Three out of four Dutch children with DS entered mainstream primary education, however late entry and high dropout are common.

[Young people with Down syndrome: independence and social functioning]

OBJECTIVE

To determine the level of independence and social functioning in young people with Down syndrome.

DESIGN

Cross-sectional study.

METHOD

Via the Dutch Down Syndrome Foundation (Stichting Downsyndroom), we asked parents of children with Down syndrome born in 1992, 1993 or 1994 to complete a written questionnaire about their child. This questionnaire contained the following standardised lists: the 'Dutch social competence rating scale for people with a learning disability', the 'Child behaviour checklist' and the 'Children's social behaviour questionnaire', and additional questions on background characteristics. The results of this Dutch cohort were compared with available data on peers without Down syndrome.

RESULTS

Data from 322 young people with Down syndrome, mean age 18.4 years (range 16.8-19.9 years), were collected (response 63%). Almost 60% of participants mastered basic skills of independent functioning, such as maintaining adequate standards of personal hygiene, preparing breakfast and being able to spend at least 30 minutes at home alone. About 10% of the participants had basic skills such as cooking and paying in a shop. Nine out of ten participants had more problems with social functioning than peers without Down syndrome, mainly with social interaction, processing information and regulating their emotions. Half of the participants had clinically relevant behavioural problems.

CONCLUSION

The results of this study show that young people with Down syndrome have limited practical and social skills, and more behavioural problems than their peers without Down syndrome. In daily life they are to a greater or lesser extent dependent on others, and need lifelong support.

Practical and social skills of 16-19-year-olds with Down syndrome: independence still far away

Survival of children with Down syndrome (DS) has improved considerably, but insight into their level of daily functioning upon entering adulthood is lacking. We collected cross-sectional data from a Dutch nationwide cohort of 322 DS adolescents aged 16-19 (response 62.8%) to assess the degree to which they master various practical and social skills, using the Dutch Social competence rating scale and the Children's Social Behavior Questionnaire. Up to 60% mastered some of the skills required for independent functioning, such as maintaining adequate standards of personal hygiene and preparing breakfast. Less than 10% had achieved basic skills such as basic cooking and paying in a shop. It is difficult for DS people to master all the skills necessary to live independently. Ninety percent of adolescents with DS experience significant problems in social functioning.

A new protocol for screening adults presenting with their own medical problems at the Emergency Department to identify children at high risk for maltreatment

Identifying child abuse and neglect solely on the grounds of child characteristics leaves many children undetected. We developed a new approach (Hague protocol) based on characteristics of parents who attend the Emergency Department (ED) because they have the following problems: (1) intimate partner violence, (2) substance abuse, or (3) suicide attempt or other serious psychiatric problems. The goal of this protocol is to enable the Reporting Center for Child Abuse and Neglect (RCCAN) to rapidly assess family problems and offer voluntary community based support to these parents. The aim of this study is to assess whether this protocol for screening adults presenting for care in the Emergency Department can identify children at high risk for maltreatment. A before and after study was conducted at 9 EDs in 3 regions in the Netherlands (one intervention region and 2 control regions). During the period January 2006 to November 2007, prior to the introduction of the Hague protocol, from a total of 385,626 patients attending the ED in the intervention region 4 parents (1 per 100,000) were referred to the RCCAN. In the period after introduction of the protocol (December 2007 to December 2011), the number rose to 565 parents from a total of 885,301 patients attending the ED (64 per 100,000). In the control region, where the protocol was not implemented, these figures were 2 per 163,628 (1 per 100,000) and 10 per 371,616 (3 per 100,000) respectively (OR=28.0 (95 CI 4.6-170.7)). At assessment, child abuse was confirmed in 91% of referred cases. The protocol has a high positive predictive value of 91% and can substantially increase the detection rate of child abuse in an ED setting. Parental characteristics are strong predictors of child abuse. Implementing guidelines to detect child abuse based on parental characteristics of parents attending the adult section of the ED can increase the detection rate of child abuse and neglect allowing appropriate aid to be initiated for these families.

Problem behavior of individuals with Down syndrome in a nationwide cohort assessed in late adolescence

OBJECTIVE

To assess problem behavior in adolescents with Down syndrome and examine the association with sex and severity of intellectual disability.

STUDY DESIGN

Cross-sectional data of a Dutch nationwide cohort of Down syndrome children aged 16-19 years were collected using a written parental questionnaire. Problem behavior was measured using the Child Behavior Checklist and compared with normative data. The degree of intellectual disability was determined using the Dutch Social competence rating scale.

RESULTS

The response rate was 62.8% (322/513), and the mean age 18.3 years (SD ± 0.8). The total score for problem behavior was higher in adolescents with Down syndrome than in adolescents without Down syndrome (26.8 vs 16.5; P < .001). Overall, 51% of adolescents with Down syndrome had problem scores in the clinical or borderline range on 1 or more Child Behavior Checklist subscales; this is more than twice as high as adolescents without Down syndrome. Adolescents with Down syndrome had more internalizing problems than their counterparts without Down syndrome (14% and 9%, respectively, in the clinical range); the percentages for externalizing problems were almost equal (7% and 9%, respectively, in the clinical range). The highest problem scores in adolescents with Down syndrome were observed on the social problems and thought problems subscales (large to very large standardized differences). Male sex and/or more severe mental disabilities were associated with more behavioral problems.

CONCLUSIONS

Serious problem behavior is more prevalent in adolescents with Down syndrome. This demonstrates the need for a focus on general behavior improvement and on the detection and treatment of specific psychopathology in individuals with Down syndrome.

Significant impact of recurrent respiratory tract infections in children with Down syndrome

OBJECTIVE

Parents and health professionals believe that recurrent respiratory tract infections (RRTI) have a large impact on children with Down syndrome (DS). We studied the relation between parent-reported RRTI and development, behaviour and health-related quality of life (HRQoL) in 8-year-old children with DS.

METHOD

During a 3-year period, 325 children with DS were recruited for inclusion in this observational study. Parents were asked to fill in the Child Behavior Checklist and TNO-AZL Children's Quality of Life Parent Form. A psychological assistant administrated the McCarthy Scales of Children's Abilities. The children were divided into a group with presence of RRTI (RRTI (+) ) and a group without RRTI (RRTI (-) ), on the basis of parental report. Linear regression analyses were performed to assess the effect of RRTI, while correcting for the influence of confounders.

RESULTS

Compared with RRTI (-) children (n = 176), RRTI (+) children (n = 149, 46%) showed decreased mental and motor development (mean developmental age 3.67 vs. 4.08 years), more behavioural problems and lower scores on most HRQoL scales (P < 0.05). Moreover, school enrolment is less favourable in RRTI (+) children.

CONCLUSION

In 8-year-olds with DS, the children with parent-reported RRTI show more delayed development, more behavioural problems and lower HRQoL compared with the children without RRTI. Although this association does not prove a causal relationship, further studies should focus on this, because RRTI are potentially preventable.

Determinants of HPV vaccination intentions among Dutch girls and their mothers: a cross-sectional study

BACKGROUND

The Dutch government recently added universal Human Papilloma Virus (HPV) vaccination for 12-year-old girls to the existing national immunization program. The participation rate for the initial catch-up campaign for girls aged 13 to 16 years in 2009 was lower (47%) than expected (70%). To inform future HPV information campaigns, this paper examines the social and psychological determinants of the HPV vaccination intentions of girls aged 13 to 16 years and their mothers who were targeted by the Dutch catch-up campaign of 2009.

METHODS

A random sample of girls and their mothers was chosen from the Dutch vaccination register and received a letter inviting them to participate (n = 5,998 mothers and daughters). In addition, a random sample was recruited via an online panel by a marketing research company (n = 650 mothers; n = 350 daughters). Both groups were asked to complete a web-based questionnaire with questions on social demographic characteristics, social-psychological factors and HPV vaccination intention. Backward linear regression analyses were conducted to examine which social-psychological factors were most dominantly associated with vaccination intention.

RESULTS

Data from 952 mothers (14%) and 642 daughters (10%) were available for the intended analyses. The contribution of social demographic variables to the explained variance of HPV vaccination intention was small but significant for mothers (ΔR² = .01; p = .007), but not significant for daughters (ΔR² = .02; p = .17) after controlling for HPV vaccination uptake and the sample. In addition, social-psychological determinants largely contributed to the explained variance of HPV vaccination intention of mothers (ΔR² = .35; p < .001) and daughters (ΔR² = .34; p < .001). Attitudes, beliefs, subjective norms and habit strength were significantly associated with participants' HPV vaccination intentions.

CONCLUSIONS

Because of the large contribution of social-psychological variables to the explained variance of HPV vaccination intentions among the mothers and daughters, future communication strategies targeting HPV vaccination uptake should address attitudes, beliefs, subjective norms and habit strength. There is a need for longitudinal research to confirm the causality of the association between these determinants and HPV vaccination behavior indicated by this study.

[Reasons for having oneself vaccinated against HPV: implications for the future provision of information]

OBJECTIVE

To examine which factors determined the participation in HPV vaccination programme in 2009 and 2010.

DESIGN

Retrospective cross-sectional study.

METHOD

Random samples of Dutch girls who had been invited for the HPV vaccination programme in 2009 and 2010, as well as their mothers, were drawn from an Internet panel. Data were gathered by means of a web-based questionnaire.

RESULTS

The questionnaire was filled out by 243 girls and 511 mothers from cohort 2009, and by 225 girls and 250 mothers from cohort 2010. In both cohorts, the following factors were related to HPV vaccination: perceived susceptibility for cervical cancer, general opinion about the vaccine, anticipated feelings of regret about the decision made, specific beliefs (e.g. about the protective effects of the vaccine), trust in responsible authorities, perceived opinion of others about the vaccination and their HPV vaccination participation, the degree to which vaccination is taken for granted and the extent to which the decision to have oneself vaccinated is unambiguously perceived. In both cohorts, these factors explained a large and significant part of the variation in HPV vaccination; namely, 89% and 81% of the girls and 94% and 82% of the mothers from the cohorts in 2009 and 2010, respectively.

CONCLUSION

This study provides insight into the reasons behind the disappointing participation in the HPV vaccination programme. In order to increase HPV vaccination uptake, future communication should provide balanced information about facts and opinions, and advantages and disadvantages of the vaccination. There should also be room for uncertainty in the choice whether or not to have oneself vaccinated.

Development, problem behavior, and quality of life in a population based sample of eight-year-old children with Down syndrome

Objective

Children with Down syndrome (DS) have delayed psychomotor development. We investigated levels of development, problem behavior, and Health-Related Quality of Life (HRQoL) in a population sample of Dutch eight-year-old children with DS. Developmental outcomes were compared with normative data of eight-year-old children from the general population.

Method

Over a three-year-period all parents with an eight-year-old child with DS were approached by the national parent organization. Developmental skills were assessed by means of the McCarthy Scales of Children's Ability. To measure emotional and behavioral problems we used the Child Behavior Checklist. HRQoL was assessed with the TNO-AZL Children's Quality of Life questionnaire. Analyses of variance were applied to compare groups.

Results

A total of 337 children participated. Mean developmental age was substantially lower than mean calendar age (3.9 years, SD 0.87 and 8.1 years, SD 0.15 respectively). Mean developmental age was significantly lower among boys than girls (3.6 (SD 0.85) and 4.2 years (SD 0.82) respectively; p<0.001). Compared with the general population, children with DS had more emotional and behavioral problems (p<0.001). However on the anxious/depressed scale, they scored significantly more favorably (p<0.001). Significantly lower HRQoL scores for the scales gross motor skills, autonomy, social functioning and cognitive functioning were found (p-values<0.001). Hardly any differences were observed for the scales physical complaints, positive and negative emotions.

Conclusion

Eight-year-old children with DS have an average developmental delay of four years, more often have emotional and behavioral problems, and have a less favorable HRQoL compared with children from the general population.

Reliability and validity of the Spanish version of the TAPQOL: a health-related quality of life (HRQOL) instrument for 1- to 5-year-old children

OBJECTIVES

To evaluate the reliability, and construct validity of the Spanish version of the TNO-AZL preschool children quality of life (TAPQOL).

METHODS

A consecutive sample of children (3 months to 5 years old) was recruited from primary care centers and two teaching hospitals in Spain. The TAPQOL and a set of questions related to their child's health status were administered to parents. Clinical diagnoses were collected from clinical records. Principal component analysis (PCA) with varimax rotation was used to analyze the instrument's structure. Effect size (ES) and analysis of variance (ANOVA) were used to analyze differences between subgroups known to be in poor health compared to the healthy subgroup.

RESULTS

A total of 228 children participated in the study (response rate=95%). Ten of the 12 scales showed more than 30% ceiling effect. All dimensions except one had Cronbach's alpha coefficients greater than 0.7. PCA explained 75% of the variance. Healthy children in general had better scores than the other subgroups. Children at risk of poor health outcomes and those with respiratory problems scored lower in several scales than the healthy subgroup.

CONCLUSIONS

Although the Spanish TAPQOL shows a non-negligible ceiling effect, it seems to be a reliable and valid instrument for Spanish infants and toddlers, and with similar psychometric characteristics to the original version. Future studies should try to improve questionnaire's structure and assess its sensitivity to change.

[Spanish version of the TNO-AZL preschool children quality of life questionnaire (TAPQOL)]

OBJECTIVES

To obtain a Spanish version of the TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL) that would be both semantically and culturally equivalent to the original.

MATERIAL AND METHODS

The TAPQOL questionnaire was designed to measure health-related quality of life in children aged 3 months to 5 years and contains 43 questions distributed in 12 subdimensions. The Spanish version was obtained by using the forward/back-translation method with expert, bilingual translators. Cognitive debriefing interviews were carried out with the parents of healthy children and with those of children with respiratory disease.

RESULTS

During the adaptation phase, four items were modified after input from the authors of the original version to retain the meaning of the original. At the end of the adaptation process, 37 of the 43 items were classified as A, i.e. without difficulty in the adaptation. Four mothers and two fathers participated in the cognitive debriefing interviews. Four had secondary level education, and two had university level education. Their children were aged between 16 and 60 months. The average time taken to complete the questionnaire was 13.5 minutes. No comprehension problems regarding the questionnaire's content were found, and no items were modified after this phase of the study. The mothers of children with respiratory disease considered the questions related to their children's symptoms to be appropriate.

CONCLUSIONS

The Spanish version of the TAPQOL has proven to be acceptable and culturally equivalent to the original version. Future studies should investigate the psychometric properties of this questionnaire and compare them with those of the original version.

Effects of Antibullying School Program on Bullying and Health Complaints

OBJECTIVE

To evaluate the effects of an antibullying school intervention in elementary schools.

DESIGN

Two-year follow-up randomized intervention group-control group.

SETTING

Forty-seven elementary schools in the Netherlands.

PARTICIPANTS

Three thousand eight hundred sixteen children aged 9 to 12 years.

INTERVENTION

During the first study year, an antibullying school program was implemented in the schools in the intervention group.

MAIN OUTCOME MEASURES

A questionnaire measuring bullying behavior, depression, psychosomatic complaints, delinquent behavior, and satisfaction with school life and peer relationships was filled out by the students at 3 times to obtain the following data: a baseline measurement, a first-effect measurement at the end of the first year, and a second-effect measurement at the end of the second year.

RESULTS

The number of bullied children decreased by 25% in the intervention group compared with the control group (relative risk, 0.75; 95% confidence interval, 0.57-0.98). The intervention group also showed a decline in the scale scores of victimization (-1.06 vs 0.28; P< .01) and active bullying behaviors (-0.47 vs 0.12, P< .05). Self-reported peer relationships also improved in the intervention schools (0.48 vs 0.11; P< .05), and there was a trend for a decrease in reported depression in the intervention schools (-0.33 vs -0.10; P< .10). At follow-up, there were no differences between the intervention and control groups for the outcome measures. Schools had also lowered their antibullying activities during the second study year.

CONCLUSIONS

An antibullying school policy can reduce bullying behavior. To keep bullying at a consistently low level, schools must continue antibullying measures every year. Continued counseling may help schools in their efforts to establish a lasting antibullying policy.

Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms

OBJECTIVES

A number of studies have shown that victimization from bullying behavior is associated with substantial adverse effects on physical and psychological health, but it is unclear which comes first, the victimization or the health-related symptoms. In our present study, we investigated whether victimization precedes psychosomatic and psychosocial symptoms or whether these symptoms precede victimization.

DESIGN

Six-month cohort study with baseline measurements taken in the fall of 1999 and follow-up measurements in the spring of 2000.

SETTING

Eighteen elementary schools in the Netherlands.

PARTICIPANTS

The study included 1118 children aged 9 to 11 years, who participated by filling out a questionnaire on both occasions of data collection.

OUTCOME MEASURES

A self-administered questionnaire measured victimization from bullying, as well as a wide variety of psychosocial and psychosomatic symptoms, including depression, anxiety, bedwetting, headaches, sleeping problems, abdominal pain, poor appetite, and feelings of tension or tiredness.

RESULTS

Victims of bullying had significantly higher chances of developing new psychosomatic and psychosocial problems compared with children who were not bullied. In contrast, some psychosocial, but not physical, health symptoms preceded bullying victimization. Children with depressive symptoms had a significantly higher chance of being newly victimized, as did children with anxiety.

CONCLUSIONS

Many psychosomatic and psychosocial health problems follow an episode of bullying victimization. These findings stress the importance for doctors and health practitioners to establish whether bullying plays a contributing role in the etiology of such symptoms. Furthermore, our results indicate that children with depressive symptoms and anxiety are at increased risk of being victimized. Because victimization could have an adverse effect on children's attempts to cope with depression or anxiety, it is important to consider teaching these children skills that could make them less vulnerable to bullying behavior.

Cost-effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal disease

OBJECTIVE

To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline.

DESIGN

Cost-effectiveness analysis based on decision model.

SETTING

Obstetric care system in the Netherlands.

POPULATION/SAMPLE

Hypothetical cohort of 200,000 neonates.

METHODS

A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY).

RESULT

The risk-based strategy will prevent 352 cases of early-onset GBS for 5.0 million Euros, indicating a cost-effectiveness ratio of 7600 Euros per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of 59,300 Euros per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio.

CONCLUSION

In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable.

Are age references for waist circumference, hip circumference and waist-hip ratio in Dutch children useful in clinical practice?

The aim of this study was to present age references for waist circumference (WC), hip circumference (HC), and waist/hip ratio (WHR) in Dutch children. Cross-sectional data were obtained from 14,500 children of Dutch origin in the age range 0-21 years. National references were constructed with the LMS method. This method summarises the distribution by three smooth curves representing skewness (L curve), the median (M curve), and coefficient of variation (S curve). The correlations between body mass index-standard deviation score (BMI-SDS), the circumferences and their ratio, and demographic variables were assessed by (multiple) regression analysis for three age groups: 0-<5 years (1), 5-<12.5 years (2), and 12.5-<21 years (3). A cut-off for clinical use was suggested based on the International Obesity Task Force criteria for BMI. Mean WC and HC values increased with age. Mean WC was slightly higher in boys than in girls, and this difference was statistically significant from 11 years of age onwards. In contrast, HC was significantly higher in girls than in boys from 9 years onwards. The correlation between WC-SDS and BMI-SDS ( r =0.73, P <0.01) and between HC and BMI-SDS ( r =0.67, P <0.01) increased with age. With regard to WHR-SDS, a low correlation was found for 12.5-20 years of age ( r =0.2, P <0.01). WC-SDS correlated positively with height SDS ( r =0.35, P <0.01).

CONCLUSION

Waist circumferences can be used to screen for increased abdominal fat mass in children, whereby a cut-off point of 1.3 standard deviation score seems most suitable.

Bullying: who does what, when and where? Involvement of children, teachers and parents in bullying behavior

Bullying victimization is associated with several health issues. Prevention of bullying is therefore an important goal for health and education professionals. In the present study, 2766 children from 32 Dutch elementary schools participated by completing a questionnaire on bullying behavior, and the involvement of teachers, parents and classmates in bullying incidents. The results of this study show that bullying is still prevalent in Dutch schools. More than 16% of the children aged 9-11 years reported being bullied on a regular basis and 5.5% reported regular active bullying during the current school term. Almost half of the bullied children did not tell their teacher that they were being bullied. When teachers knew about the bullying, they often tried to stop it, but in many cases the bullying stayed the same or even got worse. With regard to active bullying, neither the majority of the teachers nor parents talked to the bullies about their behavior. Our results stress the importance of regular communication between children, parents, teachers and health care professionals with regard to bullying incidents. In addition, teachers need to learn effective ways to deal with bullying incidents. Schools need to adopt a whole-school approach with their anti-bullying interventions.

Bullying behavior and associations with psychosomatic complaints and depression in victims

OBJECTIVES

To assess the association between bullying behavior and a wide variety of psychosomatic health complaints and depression. Study design In a cross-sectional study, 2766 elementary school children age 9 to 12 years filled out a questionnaire on bullying behavior and health complaints. Three groups-bullied children, active bullies, and children who both bully and are bullied-were compared with the group of children not involved in bullying behavior. Subsequently, risks for psychosomatic symptoms and depression were calculated by means of odds ratios.

RESULTS

Bully victims had significantly higher chances for depression and psychosomatic symptoms compared with children not involved in bullying behavior. Odds ratios were as follows: headache, 3.0; sleeping problems, 2.4; abdominal pain, 3.2; bed-wetting, 2.9; feeling tired, 3.4; and depression, 7.7. Children who actively bullied did not have a higher chance for most of the investigated health symptoms.

CONCLUSIONS

Being bullied is strongly associated with a wide range of psychosomatic symptoms and depression. These associations are similar to the complaints known to be associated with child abuse. Therefore, when such health complaints are presented, pediatricians and other health care workers should also be aware of the possibility that a child is being bullied to take preventive measures.

Health-related quality of life in relation to gender and age in couples planning IVF treatment

BACKGROUND

Specific subgroups of people planning IVF might be at risk of having more psychological or health-related problems. Identification of subgroups at risk may better enable allocation of appropriate counselling.

METHODS

A group of 425 men and 447 women planning to undergo IVF treatment filled out a questionnaire. Four domains of health-related quality of life were measured, namely perceived emotional, physical, cognitive and social functioning.

RESULTS

Young men and women (aged 21-30 years) planning IVF had more short-term social and emotional problems than people of the same age group in the general population. No substantial differences were found in cognitive and physical functioning for all age groups of men nor women planning IVF compared with the general population. A high level of irrational parenthood cognitions substantially accounted for a less optimal score on all the different domains of quality of life. These cognitions ('needing a child in order to live a happy life') were especially prevalent among younger women.

CONCLUSIONS

Patients with high levels of irrational parenthood cognitions are at risk of a less optimal quality of life. A short cognitive counselling therapy is advised for patients with high levels of these cognitions.

Unidimensionality and reliability under Mokken scaling of the Dutch language version of the SF-36

The sub-scales of the SF-36 in the Dutch National Study are investigated with respect to unidimensionality and reliability. It is argued that these properties deserve separate treatment. For unidimensionality we use a non-parametric model from item response theory, called the Mokken scaling model, and compute the corresponding scalability coefficients. We estimate reliability under the Mokken model, assuming that the items are double homogeneous, and compare it to Cronbach's alpha. The scalability of the sub-scale general health perceptions is medium (H = 0.46), and for the other sub-scales it is strong (H > or = 0.6). The reliability in terms of alpha indicates that all sub-scales can be used in basic research (alpha > 0.70), but that only physical functioning can be used for clinical applications of quality of life (alpha > 0.90). The relative merits of our approach are discussed.

Quality of life in preschool children born preterm

The relationship of preterm birth to health-related quality of life (HRQoL) was examined for children aged 1 to 4 years. Three gestational age groups with a NICU history were selected, <32 weeks (n=65), 32 to 36 weeks (n=41), 237 weeks (n=54), and a reference group from the open population (n=50). The main instrument was the TNO-AZL Preschool Quality Of Life (TAPQOL) questionnaire, which was completed by the parents. In addition, other outcome measures obtained from parents or neonatologists were investigated. Children born <32 weeks had significantly lower HRQoL than the reference group in the scales for lungs, stomach, eating disorders, motor functioning, communication, and anxiety. Parental feelings towards the child were related to the child's HRQoL. We found differences between the neonatologists' and parents' perceptions of the children's situation, which can have clinical consequences (e.g. different opinions about what needed treatment). Neonatal intensive care after birth has HRQoL implications for all children, particularly in children born at <32 weeks of gestation.

Development and psychometric evaluation of the TAPQOL: a health-related quality of life instrument for 1-5-year-old children

The 43-item TNO-AZL Preschool Children Quality of Life (TAPQOL) questionnaire was developed to meet the need for a reliable and valid instrument for measuring parent's perceptions of health-related quality of life (HRQoL) in preschool children. HRQoL was defined as health status in 12 domains weighted by the impact of the health status problems on well-being. The aim of this study was to evaluate the psychometric performance of the TAPQOL. A sample of 121 parents of preterm children completed the TAPQOL questionnaire (response rate 88%) as well as 362 parents of children from the general population (response rate 60%). On the base of Cronbach's alpha, item-rest correlation, and principal component analysis, the TAPQOL scales were constructed from the data for the preterm children sample. The psychometric performance of these scales was evaluated for both the preterm children sample and the general population sample. Cronbach's alpha ranged from 0.66 to 0.88 for the preterm children sample and from 0.43 to 0.84 for the general population sample. The unidimensionality of the separate scales was confirmed by principal component analysis for both the preterm children sample and the general population sample. Spearman's correlation coefficients between scales were, on average, low. T-tests showed that the very preterm children, the children with chronic diseases, the less healthy and the less happy children had lower mean scores on the TAPQOL scales than healthy children, indicating a worse quality of life. This study shows that the TAPQOL is a reliable and valid parent's perception of HRQoL in preschool children. More research is needed to evaluate the psychometric performance of the TAPQOL in different clinical populations.

Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations

The primary objectives of this research were to translate, validate, and generate normative data on the SF-36 Health Survey for use among Dutch-speaking residents of the Netherlands. Translation of the SF-36 into Dutch followed the stepwise, iterative procedures developed by the IQOLA Project. Following extensive pilot testing, the SF-36 was administered to: (1) a random sample of adult residents of Amsterdam (n = 4172); (2) a random, nationwide sample of adults (n = 1742); (3) a sample of migraine sufferers (n = 423); and (4) a sample of cancer patients undergoing active anti-neoplastic treatment (n = 485). Data quality across the four studies was consistently high. The rates of missing data ranged from 1% to 5% at the item level, and from 1.2% to 2.6% at the scale level. Multitrait scaling analysis confirmed the hypothesized scale structure of the SF-36 and associated scale scoring in all four samples. Cronbach's alpha coefficients surpassed the 0.70 criterion for group comparisons in all but one case (the Social Functioning scale in the cancer sample), with a mean alpha coefficient across all scales and samples of 0.84. Known-group comparisons yielded consistent support for the validity of the SF-36. In the two community samples, statistically significant differences in SF-36 mean scale scores were observed as a function of age, gender, and the prevalence of chronic health conditions. In the migraine and cancer samples, mean SF-36 scale scores varied significantly as a function of various indicators of disease severity. The SF-36 profiles for the two community samples were highly similar. The cancer sample yielded the lowest SF-36 scores, with the migraine sample holding an intermediate position. On-going studies will generate data on the responsiveness of the SF-36 to within-group changes in health over time. Efforts are underway to translate and validate the questionnaire for use among ethnic minority groups in the Netherlands.

Measuring health-related quality of life in children: the development of the TACQOL parent form

Health-related quality of life (HRQoL), conceptualized as patients' own evaluations of their health status, is an important criterion in evaluation health and health care and in the treatment of individual patients. Until now, few systematic attempts have been made to develop instruments to assess the HRQoL of children using such a conceptualization. This article describes the conceptualization and results of a study aiming to develop such an instrument for children aged 6-15 years using their parents as a proxy. The feasibility and psychometric performance of the instrument were evaluated in a study of 77 patients of the paediatric out-patient clinic of Leiden University Hospital. For each of the a priori-defined domains, a parent form scale could be constructed with satisfactory reliability and moderate correlations with the other scales. Only some of the parents indicating health status problems also signalled negative reactions to these problems. This is, in our view, a strong argument for the distinction between health status and quality of life (QoL). The correlation coefficients between the parent form and a children's questionnaire were low. Overall, the psychometric performance of the TACQOL parent form looks promising, which suggests that this instrument--with some modifications--can indeed be used to assess group differences in HRQoL in children. The results, however, should be replicated in larger samples, currently under study. The relation between parents' proxy reports on the HRQoL of their children and children's self-reports needs further investigation.

Psychological responses to the needle-free Medi-Jector or the multidose Disetronic injection pen in human growth hormone therapy

The aim of the study was to test the hypothesis that daily administration of growth hormone using the Medi-Jector results in fewer adverse psychological responses than needle injection with a multidose injection pen. The Medi-Jector is a needle-free injection device that can deliver growth hormone subcutaneously through jet injection. The group studied consisted of 18 children aged 10 y or over who were participating in a study of the bioequivalence and bioequipotence of the administration of growth hormone through jet injection or needle injection. Previously, all subjects had received growth hormone therapy with commercially available multidose injection pens. The study was designed as a prospective, randomized, two-period cross-over trial. A questionnaire was used to assess psychological responses such as non-compliance, opinion on ease of preparation, affective responses to administration and local side-effects, as well as overall preference. In addition, the subjects kept a diary during the study. The subjects found the Medi-Jector less offputting (p < 0.01), less painful with respect to both frequency (p < 0.04) and intensity (p < 0.01) and less unpleasant (p < 0.05) than a multidose injection pen with a 28G needle (p < 0.01). No difference in compliance was detected. Most subjects preferred the Medi-Jector for future use (p < 0.05). The mean score on a 1-10 point scale (10 is excellent) was 7.9 (SD 1.4) for the Medi-Jector and 6.8 (SD 2.3) for the multidose injection pen (p < 0.08). The prevalence of visible bruises each day was higher (p < 0.01) with the Medi-Jector (2.5, SD 2.1) than with the multidose injection pen (0.7, SD 1.1), but children showed indifferent affective responses to bruising. Thirteen out of 18 subjects decided to continue therapy with the Medi-Jector (p < 0.06). It is concluded that use of the Medi-Jector in growth hormone therapy tends to lead to fewer adverse psychological responses than a multidose injection pen with 28G needles.