"Therapy without a therapist?" The experiences of adolescents and their parents of online behavioural activation for depression with and without therapist support.

Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression.Trial registration number: ClinicalTrials.gov Identifier NCT04117789, Date of registration: 07 October 2019.

Women's experiences of psychological treatment and psychosocial interventions for postpartum depression: a qualitative systematic review and meta-synthesis.

BACKGROUND: To provide a comprehensive, systematic evaluation of the literature on experiences of psychological interventions for postpartum depression (PPD) in women. Depression is one of the most common postpartum mental disorders. Studies have identified that psychological interventions reduce depressive symptoms. However, less is known about the experiences of women who have received such treatments. METHODS: A systematic review of the literature was conducted by searching five databases (CINAHL, Cochrane Library, EMBASE, Medline, PsycINFO), in August 2022. Studies with qualitative methodology examining women's experiences of professional treatment for PPD were included and checked for methodological quality. Eight studies (total N = 255) contributed to the findings, which were synthesized using thematic synthesis. Confidence in the synthesized evidence was assessed with GRADE CERQual. FINDINGS: The women had received cognitive behavioral therapy (5 studies) or supportive home visits (3 studies). Treatments were individual or group-based. Two main themes were identified: Circumstances and expectations, and Experiences of treatment, with six descriptive themes. Establishing a good relationship to their health professional was important for the women, regardless of treatment model. They also expressed that they wanted to be able to choose the type and format of treatment. The women were satisfied with the support and treatment received and expressed that their emotional well-being had been improved as well as the relationship to their infant. CONCLUSION: The findings can be helpful to develop and tailor patient-centered care for women who are experiencing postnatal depression.

Prospective associations between psychosomatic complaints in adolescence and depression and anxiety symptoms in young adulthood: A Swedish national cohort study.

Background: Psychosomatic complaints are reported by high shares of adolescents in Sweden and elsewhere. Yet, little is known about to the extent to which the frequency, number, and persistence of such complaints in adolescence are associated with subsequent mental health problems. The aim of this study was to examine how the frequency, number, and persistence of psychosomatic complaints in middle and late adolescence are associated with depression and anxiety symptoms in young adulthood. Methods: A Swedish national cohort study of adolescents who were surveyed in 2017 (t1; age 15-16), in 2019 (t2; age 17-18) and in 2022 (t3; age 20-21 years) was used. Psychosomatic complaints were measured by questions on stomach ache, headache and difficulties falling asleep at t1 and t2. Depression and anxiety symptoms were measured by the Patient Health Questionnaire-4 (PHQ-4) at t3. Multivariable binary logistic regression analyses stratified by gender were based on data from t1, t2 and t3 (n = 2779). Results: The frequency, number, and persistence of psychosomatic complaints during adolescence were associated with symptoms of depression and anxiety in young adulthood. Both earlier (at t1 only) and more recent (at t2 only) complaints were linked to subsequent depression and anxiety symptoms, while persistent (at both t1 and t2) psychosomatic complaints showed stronger associations in girls. Conclusions: Psychosomatic complaints in adolescence were associated with depression and anxiety symptoms in young adulthood. This was true for the frequency, number, and persistence of psychosomatic complaints. Among girls, those who reported persistent psychosomatic complaints from middle to late adolescence had the highest likelihood of reporting subsequent depression and anxiety symptoms. Taken together, the results indicate that psychosomatic complaints during adolescence can translate into later depression and anxiety symptoms. Furthermore, repeated measurements of psychosomatic complaints can be used to identify the most vulnerable group.

Little All Children in Focus (Little ACF), evaluation of a parental support program for parents of children aged 1-2 years: study protocol for a randomized controlled trial.

BACKGROUND: Child health and development can be promoted by strengthening and supporting parents. Research on parental support programs based on positive psychology and a health-promoting approach aimed at all parents, and in particular parents of infants is limited. All Children in Focus (ACF) is a parental support program that has been evaluated in a randomized trial in parents of children 3-12 years. The ACF is based on health promotion aiming to increase parents' confidence and child's well-being. In the current study, we will study the effects of a revised version of the ACF called Little ACF adapted to parents with children aged 1-2 years. METHODS: The study includes a randomized controlled trial (RCT) taking place at several Child Health Centers (CHCs) in Sweden. The RCT will evaluate the efficacy of Little ACF (intervention) in comparison with four digital lectures about child development and parenting (active control). Parents are recruited at the 10-, 12-, or 18-month visits to CHC by CHC-nurses. Data to assess changes in parental competencies and child socio-emotional development are collected through online questionnaires completed by parents at five time points: baseline, post-intervention, after 6 and 12 months, and when the child is 3 years old. DISCUSSION: The paper describes a study protocol of a randomized controlled trial evaluating the effects of a parental support program during infancy. Several issues related to the methodology and implementation are discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT05445141. Registered on 6 July 2022.

The Cost of Obsessive-Compulsive Disorder in Swedish Youth.

The economic impact of pediatric obsessive-compulsive disorder (OCD) on society is unknown. We compared a wide range of individual-level cost data of children 7-17 years with OCD (n = 152) with a control group from the general population in Sweden (n = 768). The total annual cost in the OCD group was M = 11941€ (95%CI [9915-13966]), compared to the control group M = 6380 € (95%CI [5461-7299]), corresponding to an estimated marginal mean cost of OCD of 5560 € per person and year (z = 4.99, p < .001). OCD was associated with significantly higher healthcare costs, parental absence from work and school productivity loss. OCD symptom severity was positively associated with higher costs. The total societal burden of pediatric OCD in Sweden was estimated to be 94.3 € million per year (95%CI [56.9-131.8]). These results have important implications for policy makers and for the allocation of healthcare resources. Similar studies are needed in other countries in order to estimate the global cost of the disorder.

Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial.

Parent management training (PMT) is recommended treatment for children with oppositional defiant disorder (ODD) and child-directed cognitive behavior therapy (CBT) is also recommended for school-aged children. The current study examined 2-year follow-up effects of parent management training (PMT) combined with the CBT based group intervention Coping Power Program (CPP) compared to PMT only. Results showed long-term effectiveness of both PMT and PMT combined with CPP in reduced disruptive behavior problems and harsh parenting strategies, and increased emotion regulation- and social communication skills. The earlier reported increase in emotion regulation- and social communication skills in the PMT with CPP condition during treatment remained stable while the PMT condition showed continued improvement during the follow-up period. To conclude, PMT with CPP did generally not provide significant benefits at the 2-year follow-up compared to PMT, apart from an improvement earlier in time regarding emotion regulation- and social communication skills.Trial registration number ISRCTN10834473, date of registration: 23/12/2015.

Obsessional jealousy in a community sample: Association with relationship factors, impairment and perceived treatment needs.

OBJECTIVES: Romantic jealousy could be understood as a continuum, from reality-based, transient and functional jealousy to a more chronic form of jealousy with varying insight, intensity and duration. The latter has some overlaps with obsessive-compulsive disorder (here termed obsessional jealousy). Little is known about the nature of obsessional jealousy and its association with functional impairment, perceived negative consequences (drinking, violence), current and past relationship factors (e.g., length of relationship, being in love, infidelity, previous jealousy) or perceived need for professional support. METHODS: Participants were 1076 adults (55% women) who filled in an anonymous survey. RESULTS: Obsessional jealousy, measured with the Obsessional Jealousy Severity Scale, was strongly associated with functional impairment and verbal violence, and more weakly with physical violence and alcohol consumption. Individuals with a history of previous jealousy had more severe symptoms and were more likely to perceive the need for psychological support. Approximately 25% of the sample expressed interest in treatment. CONCLUSIONS: The results suggest that there is a group of individuals with impairing levels of obsessional jealousy who have a perceived need for help with their difficulties. More research is needed on the prevalence and clinical characteristics of these individuals. The development of jealousy-specific psychological models and treatments is warranted.

Developing a Brief Parent Training Intervention to Prevent Anxiety in Offspring.

Offspring of parents with anxiety disorders have an increased risk of developing anxiety themselves. Very few studies have evaluated interventions aiming to prevent anxiety in offspring of anxious parents. This study was a small (N=40) randomized pilot study with three arms evaluating the feasibility of a novel parent support group for anxious parents, the Supporting Anxious Parents Program (SAPP). The primary objective was to evaluate the acceptability of the SAPP. In addition, we also evaluated preliminary effects on child anxiety, parent risk factors, and quality of life, and feasibility of the study design. Excessive parental worry and anxiety and having a child not meeting criteria for an anxiety disorder (6-12 years old), served as inclusion criteria. Thirteen parents were randomly allocated to a group-based intervention, 14 to an individual Internet-based version of the intervention, and 13 to a waitlist control condition. The intervention was developed to target three risk factors involved in the parent-child transmission of anxiety; criticism/low warmth, overprotective behaviors, and modeling of anxiety. The results showed that parents were generally very satisfied with the intervention. We did not find any significant decreases in child anxiety in the intervention conditions. However, for the parents, we found preliminary support for reduced overprotective behaviors, reduced worry, and increased quality of life. The study design was found to be feasible. According to the results, a revision of the intervention is recommended before a full randomized controlled trial could be conducted.

Therapist-guided and self-guided internet-delivered behavioural activation for adolescents with depression: a randomised feasibility trial.

OBJECTIVE: Access to effective treatments for adolescents with depression needs to improve. Few studies have evaluated behavioural activation (BA) for adolescent depression, and none remotely delivered BA. This study explored the feasibility and acceptability of therapist-guided and self-guided internet-delivered BA (I-BA) in preparation for a future randomised controlled trial (RCT). DESIGN: A single-blinded randomised controlled feasibility trial. SETTING: A specialist outpatient clinic in Sweden. PARTICIPANTS: Thirty-two adolescents with mild-to-moderate major depression, aged 13-17 years. INTERVENTIONS: Ten weeks of therapist-guided I-BA or self-guided I-BA, or treatment as usual (TAU). Both versions of I-BA included parental support. TAU included referral to usual care within child and youth psychiatry or primary care. OUTCOMES: Feasibility measures included study take-up, participant retention, acceptability, safety and satisfaction. The primary outcome measure was the blinded assessor-rated Children's Depression Rating Scale, Revised. The primary endpoint was the 3-month follow-up. RESULTS: 154 adolescents were screened and 32 were randomised to therapist-guided I-BA (n=11), self-guided I-BA (n=10) or TAU (n=11). Participant retention was acceptable, with two drop-outs in TAU. Most participants in TAU had been offered interventions by the primary endpoint. The mean number of completed chapters (total of 8) for adolescents was 7.5 in therapist-guided I-BA and 5.4 in self-guided I-BA. No serious adverse events were recorded. Satisfaction was acceptable in both I-BA groups. Following an intent-to-treat approach, the linear mixed-effects model revealed that both therapist-guided and self-guided I-BA (Cohen's d=2.43 and 2.23, respectively), but not TAU (Cohen's d=0.95), showed statistically significant changes on the primary outcome measure with large within-group effect sizes. CONCLUSIONS: Both therapist-guided and self-guided I-BA are acceptable and potentially efficacious treatments for adolescents with depression. It is feasible to conduct a large-scale RCT to establish the efficacy and cost-effectiveness of I-BA versus TAU. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04117789).

Psychometric evaluation of a Swedish version of the Impaired Control Scale for individuals with alcohol use disorder.

Aim: The aim of this study was to evaluate the psychometric properties of a Swedish version of the Impaired Control Scale. Impaired control (IC) over alcohol consumption is a core symptom of alcohol use disorder and a predictor of treatment outcome, but measures of IC are not well utilised in clinical practice. Methods: The study comprised 250 individuals from a randomised controlled trial conducted at an adult outpatient addiction clinic in Sweden. The statistical analyses concern dimensionality, convergent and divergent validity, reliability, measurement invariance and sensitivity to change. Results: Regarding dimensionality, a principal component analysis of the standardised residuals from a Rasch model indicated some evidence of further dimensions underlying the responses in the Failed Control (FC) and Perceived Control (PC) parts. Two parallel items (12 and 22 respectively) seemed to drive potential multidimensionality. When these items were excluded, goodness of fit to one-dimensional models was improved. Tests of convergent and divergent validity showed that failed control had the strongest associations to impaired control and alcohol use disorder while the attempted control part was not associated with the construct of impaired control or alcohol use disorder. Conclusion: The present results show that the FC part is the most valid measure of the underlying construct of IC. In addition, FC had close to a large effect in regard to sensitivity to change. This suggests that the FC part has potential utility for use as an assessment and evaluation tool of treatment effect on impaired control of drinking.

Cross-sectional associations between physical activity pattern, sports participation, screen time and mental health in Swedish adolescents.

OBJECTIVES: To investigate the associations between physical activity pattern, sports participation, screen time and mental health in Swedish adolescents. DESIGN, SETTING AND PARTICIPANTS: A total of 1139 Swedish adolescents (mean age 13.4) from 34 schools participated in the cross-sectional study 'Physical Activity for Healthy Brain Functions in School Youth' in 2019. METHODS: Time spent sedentary and in moderate-to-vigorous physical activity (MVPA) was measured using accelerometers for seven consecutive days. Screen time and sports participation were self-reported. Anxiety and health-related quality of life (HRQoL) were assessed using a Short version of the Spence Children's Anxiety Scale and Kidscreen-10. RESULTS: MVPA was positively associated (95% CI 0.01 to 0.05 in girls and 0.02 to 0.07 in boys) whereas screen time on weekdays was inversely associated with HRQoL (-4.79 to -2.22 in girls and -2.66 to -0.41 in boys). The largest effect sizes were observed between the high/low MVPA group in boys (Cohen's d=0.51) and screen time groups in girls (Cohen's d=0.59 on weekdays). With regards to anxiety, high compared with lower time spent in MVPA during leisure time on weekdays was associated with lower anxiety scores (95% CI -0.13 to -0.05 in girls and -0.07 to -0.01 in boys). Gender differences were observed, boys who participated in organised sports had low anxiety scores (95% CI -3.49 to -0.13) whereas girls who reported 5 hours or more of screen time had high scores (95% CI 1.94 to 6.18 on weekdays and 1.39 to 5.29 on weekend days). CONCLUSIONS: This study showed that MVPA was associated with better mental health, whereas the opposite was seen for screen time. These associations were not consistently significant throughout all time domains, between the genders and mental health outcomes. Our results could create a paradigm for future studies to decide which types of PA patterns and time domains to target in intervention studies with the aim improve mental health among adolescents.

Clozapine treatment and risk of severe COVID-19 infection.

OBJECTIVE: To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID-19 infection as compared with patients on other antipsychotic drugs. METHODS: In this register-based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from 1 March 2020 to 14 January 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID-19 infection) were: inpatient care, care within intensive care unit or death due to COVID-19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. CONCLUSIONS: Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID-19 pandemic with careful monitoring and readiness to alter drug doses as needed.

Development and validation of the Modeling of Parental Anxiety Questionnaire.

Parental anxious modeling is assumed to be a risk factor for child anxiety. Until now there has been no self-assessment scale available that measures parental modeling of anxiety in a comprehensive way. Our aim with this study was to bridge this gap by developing the Modeling of Parental Anxiety Questionnaire (MPAQ). To do this, we generated an item pool containing 51 statements covering different aspects of parental modeling of anxious and non-anxious behaviors. A sample of Swedish parents (N = 1092) of children aged 4-12, answered an online survey comprising the generated item pool, the Parental Overprotection Scale (OP) and the PROMIS Anxiety short forms (the adult version and the parent proxy report scale). A factor analysis of the items of parental modeling indicated a structure with four separate factors. These factors formed the final four subscales of MPAQ; (1) being curios and content, (2) being on guard, (3) displaying anxiety and avoidance, and (4) displaying stress. The Cronbach's alpha coefficients of the subscale scores ranged from moderate to good. Linear regression analysis showed that the displaying anxiety and avoidance-subscale had the strongest association with child anxiety symptoms. These findings show that MPAQ demonstrates adequate psychometric properties and has potential for being used in research and clinical settings, for example to identify potential targets for parenting interventions and to measure mediation effects.

Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a meta-ethnography.

OBJECTIVES: To develop conceptual understanding of perceived barriers to seeking care for migrant children and young people (aged 0-25 years) with mental health problems and/or neurodevelopmental differences in high-income countries. DESIGN: Qualitative evidence synthesis using meta-ethnography methodology. We searched four electronic databases (Medline, PsycINFO, Global Health and Web of Science) from inception to July 2019 for qualitative studies exploring barriers to care (as perceived by migrant communities and service providers) for migrant children and young people in high-income countries with neurodevelopmental differences and/or mental health problems. The quality of included studies was explored systematically using a quality assessment tool. RESULTS: We screened 753 unique citations and 101 full texts, and 30 studies met our inclusion criteria. We developed 16 themes representing perceived barriers to care on the supply and demand side of the care-seeking process. Barriers included: stigma; fear and mistrust of services; lack of information on mental health and service providers lacking cultural responsiveness. Themes were incorporated into Levesque et al's conceptual framework of patient-centred access to healthcare, creating a version of the framework specific to migrant children and young people's mental health and neurodevelopmental differences. CONCLUSIONS: This is the first qualitative evidence synthesis on barriers to care for mental health problems and/or neurodevelopmental differences in migrant children and young people in high-income countries. We present an adapted conceptual framework that will help professionals and policy-makers to visualise the complex nature of barriers to care, and assist in improving practice and designing interventions to overcome them. Similar barriers were identified across study participants and migrant populations. While many barriers were also similar to those for children and young people in general populations, migrant families faced further, specific barriers to care. Interventions targeting multiple barriers may be required to ensure migrant families reach care.

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial.

Importance: Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited. Objective: To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT). Design, Setting, and Participants: This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study. Interventions: ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist. Main Outcomes and Measures: The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs. Results: Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group. Conclusions and Relevance: In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. Trial Registration: ClinicalTrials.gov Identifier: NCT03247075.

Dimension-specific symptom patterns in trajectories of broad anxiety: A longitudinal prospective study in school-aged children.

Theories of maladaptive anxiety in children have suggested different developmental trajectories across age. Weems (2008) suggested that one subgroup of children demonstrates high and stable levels of broad anxiety, but shifting levels of dimension-specific symptoms in part due to related normative challenges. In a prospective longitudinal design, the current study examined patterns of dimension-specific anxiety symptoms in subgroups of children following different developmental trajectories of broad anxiety. A total of 300 children (150 girls, 150 boys) ages 8-11 at baseline, completed the Spence Children's Anxiety Scale four times over 3 years. Using latent class growth mixture modeling, we found evidence of three subgroups of children following different trajectories of broad anxiety across age: low-stable, moderate-increasing, and high-decreasing. Compared with other children, the subgroup with moderate and increasing levels of broad anxiety demonstrated an initially higher level of separation anxiety with larger improvement across time but, initially, similar levels of generalized and social anxiety with a larger increase across age. High broad anxiety was partly carried by different sets of dimension-specific symptoms at different ages, which suggests that children with high levels of broad anxiety across time may be more sensitive to normative challenges that happen in typical child development.

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

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

School Climate, Academic Achievement and Educational Aspirations in Roma Minority and Bulgarian Majority Adolescents.

BACKGROUND: School climate can promote students' academic achievement and high educational aspirations. School climate refers to the quality and character of school life, norms, values, social interactions and organizational processes within a school. OBJECTIVE: We examined for the present sample whether (a) school climate relates to academic achievement and educational aspirations and (b) such relations vary for Roma minority compared to their majority peers. METHOD: Participants in this cross-sectional study were 356 adolescents aged 11-19 years old (159 Roma, 197 Bulgarian majority), 332 mothers (149 Roma, 183 majority), 231 fathers (104 Roma, 127 majority) and 221 majority teachers who completed self-report surveys to address the study goals. Adolescents provided data on educational aspirations and academic achievement, parents on their children's educational aspirations and teachers reported on school climate. We employed linear mixed models to explore associations of school climate, academic achievement and educational aspirations among Roma and Bulgarian majority youth. RESULTS: There were negative associations between teacher-reported school climate and students' academic achievement, as well as adolescent and parental educational aspirations for Roma adolescents only. Roma adolescents and parents reported lower academic achievement and educational aspirations than their majority counterparts. CONCLUSIONS: This study supports the relevance of school climate in relation to academic achievement and aspirations of disadvantaged minority students. Interventions should pay close attention to perceptions and attitudes in a school to successfully promote positive outcomes among students.