The proliferation of evidence-based practices has created opportunities for advancing public mental health. But despite the accumulation of empirical knowledge, the sobering reality is that the adoption of evidence-based practices is not as widespread as expected (Fixsen et al., 2010; Gonzales et al., 2002). There is a disparity between intervention need and provision, which is particularly pronounced in the field of child and adolescent mental health (Colizzi et al., 2020). Addressing this gap may require a stronger focus on pragmatic solutions that are both feasible and effective in real-world settings.
This thesis is built on three research papers that contribute insights into two of the tenets in evidence-based practice in psychology: measurement and intervention (American Psychological Association, 2021). The papers focus on components within prevention for child internalizing problems and on evidence-based measurement of child internalizing symptoms. The overarching aim of the thesis is to strengthen the foundation of evidence-based practices for children and adolescents with anxiety or depression symptoms accessing primary health care services.
First addressing the issue of intervention components, Papers 1 and 2 focused on empirical optimization of an indicated transdiagnostic Cognitive Behavioral Therapy group intervention for children and adolescents with heightened anxiety and depression symptoms. While the intervention´s effectiveness on mental health outcomes have previously been documented (Martinsen et al., 2019; Loevaas et al., 2020), its resource-intensiveness was identified as a significant barrier to implementation (Rasmussen et al., 2020). Guided by the Multiphase Optimization Framework (MOST; Collins 2018), papers 1 and 2 thus explored the effects of three distinct components: 1) Delivery Format: face-to-face group sessions versus a blended group and internet-delivered format, 2) Parental Involvement: Group-based participation versus a psychoeducational self-help brochure and 3) the integration of a Measurement Feedback System (MFS): MFS versus no MFS. Paper 1 contributed knowledge of the post-intervention effects of these components, aiming to identify the most effective and resource-efficient combination for an optimized intervention adapted to real-world needs. Paper 2 further expanded on the topic by focusing on the 12-month follow-up effects to identify components that could potentially contribute to long-term effectiveness.
Transitioning from prevention into assessment, paper 3 aimed to contribute to the validation of the Revised Child Anxiety and Depression Scale (RCADS-47; Chorpita et al., 2000 and RCADS-25; Ebesutani et al., 2017). Advocates of global standardized mental health measurement have proposed to use this measurement tool in treatment and research with children worldwide as it is free of cost, openly available, brief, and scores are easy for practitioners to interpret (Krause et al., 2021). RCADS has shown itself valid and reliable for measuring internalizing symptoms (see Lisøy et al., 2022). However, the applicability of instruments needs to be established when employed in new contexts (Prince, 2008), especially using new translations, and RCADS had not earlier been examined in a Norwegian setting. We thus investigated the psychometric properties of the Norwegian translation of the full (RCADS-47) and short (RCADS-25) child-report versions.
All three papers drew data from the large, factorial 2x2x2 optimization trial “Echo: optimizing a group-based school intervention for children with emotional problems”, in which 58 schools across Norway participated. Children attended fourth through sixth grade upon entering the study (mean age 10.7 years). After screening, 701 children with elevated anxiety or depression symptoms accepted invitation to join child intervention groups. Papers 1 and 2 used intent-to-treat analyses with data from all available participants. In paper 1, primary analyses included 633 children and 725 parents who responded post-intervention. Paper 2 included 564 children and 554 parents who responded at 12-month follow-up. The primary outcomes in papers 1 and 2 were children´s symptoms of anxiety (MASC-C/P; March et al., 1997) and depression (SMFQ-C/P; Angold et al., 1995), as reported by children and their parents. Paper 3 used cross-sectional pre-intervention data from a sub-sample of 592 children to investigate psychometric properties of the RCADS-47 and RCADS-25 youth versions.
In paper 1, while all conditions resulted in reduced levels of anxious and depressed symptoms, three findings were of primary interest. First, we did not find evidence that the type of delivery format (group versus a blended format) had a significant effect on children’s internalizing symptoms. Second, we did not find significant effects of receiving group-based parental involvement versus a parent brochure. Third, MFS usage during the intervention did not significantly impact children’s symptom levels. Paper 2 corroborated these findings at 12-month follow-up. Paper 3 found that that the Norwegian youth-report versions of RCADS-25 and RCADS-47 demonstrated good internal consistency, structural validity, strong measurement invariance across sex, and excellent convergent validity with other self-report measures for anxiety and depression.
In conclusion, paper 3 provided initial evidence indicating that the Norwegian versions of RCADS-25 and RCADS-47 are reliable and valid instruments for measuring symptoms of anxiety and depression. As such, they are promising measures for future use in Norway. The findings from papers 1 and 2 contributed knowledge about intervention delivery format, parental involvement, and MFS in the context of indicated group prevention for children and adolescents. Results suggested that a blended format, parental brochure, and no MFS should be carried forward in an optimized intervention. Such a new version of the intervention should undergo effectiveness evaluation, as questions about the effectiveness of the intervention package cannot be answered with the present trial´s factorial design. While no component, or combination of components, appeared to enhance intervention effectiveness, the lack of discernible effects may have important implications. It is encouraging that less resource-intensive combinations of intervention components, may suffice to reduce children´s internalizing symptoms. The potential to achieve positive outcomes with fewer resources holds promise for enhancing reach. In this context, the notion that “less is more” implies that a simpler intervention could have a greater impact by reaching more children.