Trends in mental health problems among Swedish adolescents: Do school-related factors play a role?

AIM: The aim of this study is to investigate the extent to which school-related factors, such as school liking, participation in decision-making, school-related parental support, teachers' support, and school physical environment, explain trends in mental health problems. The problems considered are psychosomatic symptoms (PSS), depressive symptoms (DS), suicidal ideations (SI), and suicide attempts (SA) among Swedish adolescents of varying socioeconomic status (SES) from 2004 to 2020. METHODS: We analyzed data collected through repeated cross-sectional surveys from 19,873 15-year-old students at schools in a county in Sweden. Boys and girls each constituted 50% of the participants. We fitted linear and logistic regression models to investigate associations between the school-related factors and trends in mental health problems. RESULTS: Increased school-related parental support and school liking were cross-sectionally associated with decreased PSS, DS and SI, with school liking also associated with decreased SA. Conducive school physical environment was also found to be cross-sectionally associated with lower PSS and DS scores. Over time, mental health problems have shown a general increase among adolescents in the low SES group and a decrease among those in the high SES group. While school-related factors explained the improvement in mental health in the high SES group, we found such association only between parental support trends in PSS and DS, along with participation and trends in SA over time among adolescents in the low SES group. CONCLUSIONS: The results show that school-related factors play significant roles in influencing adolescent mental health. The influence, however, varied across SES gradients over time. This suggests that working against inequities in school-related factors would help address inequities in mental health.

Trends in psychosomatic symptoms among adolescents and the role of lifestyle factors.

BACKGROUND: Adolescent mental health problems are on the rise globally, including in Sweden. One indicator of this trend is increased psychosomatic symptoms (PSS) over time. Lifestyle factors such as physical activity (PA), diet, smoking, and alcohol consumption may influence the time trends in PSS; however, the evidence base is scarce. The aim of this study was to investigate associations between time trends in PSS and lifestyle factors. METHODS: The study was based on data collected from a nationally representative sample of 9,196 fifteen-year-old boys and girls in Sweden using the Health Behavior in School-aged Children (HBSC) symptom checklist. The sample comprised nearly equal proportions of girls (50.5%) and boys. The lifestyle factors examined in this study included PA, regular breakfast intake, consumption of fruits, vegetables, sweets, or soft drinks, smoking, and alcohol drunkenness. We used data from 2002 to 2018 and stratified by family affluence scale (FAS) to demonstrate how the associations varied among the FAS groups. We fitted separate regression models for the high- and low-FAS groups, where interaction terms between the year of survey and each lifestyle factor were used to estimate the level and direction of associations between the factors and trends in PSS. RESULTS: There was a generally increasing trend in PSS mean scores from 2.26 in 2002 to 2.49 in 2018 (p <.001). The changes in each survey year compared to the average mean scores during the preceding years were significant in all years except 2010. Regular breakfast intake, daily fruit and vegetable consumption, and higher PA were associated with lower PSS mean scores, while smoking and drunkenness had opposite associations with PSS. The only significant interaction between survey year and the lifestyle factors was observed regarding drunkenness in the high FAS group, suggesting that the association between trends in PSS and the experience of getting drunk at least twice got stronger over time (B = 0.057; CI:0.016, 0.097; p <.01). CONCLUSIONS: The results indicate increasing trends in PSS among young people in Sweden from 2002 to 2018, with a significant increase observed among adolescents in the high FAS group who reported getting drunk on at least two occasions.

Trends in adolescent mental health problems 2004-2020: do sex and socioeconomic status play any role?

AIMS: This study aims to investigate trends in four types of adolescent mental health problems; that is, psychosomatic symptoms, depressive symptoms, suicidal ideations, and suicide attempts 2004-2020. A second aim is to investigate the moderating roles of socioeconomic status and sex in these trends. METHODS: The analysis is based on repeated cross-sectional data 2004-2020 among grade 9 students in secondary schools in a Swedish county. In total, data from 19,873 students were included in the analysis. We fitted linear and logistic regression equations and used survey-years' coefficients to estimate the trends. We also estimated the moderating effects of socioeconomic status and sex using interactions between survey year and socioeconomic status and sex, respectively. RESULTS: The trends in all mental health problems declined over time. Through its interaction with survey year, socioeconomic status moderated the trends; psychosomatic symptoms (B = -0.115, P<0.001), depressive symptoms (B = -0.084, P<0.001) and suicidal ideations (odds ratio 0.953, confidence interval 0.924-0.983) significantly declined over time among those with high socioeconomic status. However, socioeconomic status did not have an association with the trend in suicide attempts. Interaction between sex and year of survey was associated with significant decreasing trends in depressive symptoms and suicidal ideations only among girls. CONCLUSIONS: Adolescent mental health problems have decreased over time, but only for adolescents with high socioeconomic status, or only in depressive symptoms and suicidal ideations for girls. The results shed light on the growing inequalities in health outcomes across levels of socioeconomic status.

Do non-drinking youth drink less alcohol in young adulthood or do they catch up? Findings from a Swedish birth cohort.

BACKGROUND: Alcohol consumption among adolescents has declined considerably during the last two decades. However, it is unknown if these adolescents' alcohol consumption will remain low as they grow older. To our knowledge, this is one of the first studies that uses longitudinal data to examine if non-drinking adolescents have a lower alcohol consumption in young adulthood or if they catch up. METHODS: A self-report survey was distributed to a birth cohort (n = 794) born in 1997 in a Swedish region when cohort members attended ninth grade (age 14-15 years) in 2012. Responders were divided into non-drinkers and alcohol users and assessed again in their late teens (17-18 years) and young adulthood (20-21 years). RESULTS: In their late teens (17-18 years), non-drinkers at baseline consumed less alcohol and had a lower probability of harmful use compared with their alcohol-using peers. In young adulthood (20-21 years), these effects disappeared when adjustment was made for covariates. However, a stratified analysis showed that non-drinking adolescents low in conduct problems consumed less alcohol and had a lower probability of harmful use in young adulthood than alcohol-using peers. CONCLUSIONS: This study suggests that the decline in alcohol use among adolescents in the past decades may be associated with a lower alcohol consumption in the late teens and young adulthood among those low in conduct problems. This may have promising implications for alcohol-related morbidity and mortality.

Eleven Reasons for Adaptation of Swedish Parenting Programs.

While questions about adaptation and fidelity are of great concern in many implementation projects, less attention has been paid to reasons for adaptations that remain when evidence-based interventions (EBIs) are used in clinical and community settings. This study aims to explore reasons for adaptations that can arise when using parenting programs in a community setting. Seventeen individual interviews with providers were conducted and analyzed thematically, resulting in 11 reasons for adaptations organized into four separate areas: characteristics of group leaders (supplementary skills and knowledge, preferred ways of working), characteristics of families (problem complexity, diverse or limited educational experience, non-parenting needs for support, colliding value systems), group incidents (criticism and challenges, excessive questions or discussions), and didactic challenges (lack of focus or engagement, limitations of the material, language differences). The study shows that factors triggering adaptation and fidelity decisions continuously reappear in the provision of parenting programs in community settings. Knowledge about reasons for adaptation can be used to inform decision-making during implementation planning, as well as the sustainment of implemented interventions.

Changes in Mental Health and Views on Communication and Activities of Public Institutions among Swedes during the COVID-19 Pandemic-A Cross-Sectional Repeated Measures Design.

Although many studies have been conducted on the effects of COVID-19 on individual lives, only a few focus on the changes in mental health and views of public institutions during the pandemic. This study aimed to investigate how mental health, i.e., life satisfaction, worries, and psychological distress, and views on public institutions' communication and activities have changed among Swedes during the COVID-19 pandemic, and whether this was moderated by age and sex. In April-May 2020 (survey 1) and in January-February 2021 (survey 2), 2554 adults and 1904 newly recruited adults, respectively, anonymously completed online surveys. We found that life satisfaction and psychological distress did not change from survey 1 to survey 2. However, the level of worries increased, and the positive views of the public institutions decreased. Moreover, worries and psychological distress increased more in young adults than older adults. Finally, the change in the views of the public institutions was not related to the change in worries. Our results highlight the COVID-19 long-term impacts on individual mental health and call for the need for future research concerning the consequences for the population, especially among young adults. The results also indicate that the views on activities of public authorities decreased over time, especially among men. Given that loss of this trust can have vastly negative effects, for instance, on the vaccine campaign, it is important to monitor this trend, to increase awareness among Swedish authorities. The results also stress for institutions to provide adequate support both during the COVID-19 pandemic and in a future crisis.

Understanding the value of adhering to or adapting evidence-based interventions: a study protocol of a discrete choice experiment.

BACKGROUND: Whereas the value of an evidence-based intervention (EBI) is often determined by its effect on clinical outcomes, the value of implementing and using EBIs in practice is broader, reflecting qualities such as appropriateness, equity, costs, and impact. Reconciling these value conflicts involves a complicated decision process that has received very limited scholarly attention. Inspired by studies on decision-making, the objective of this project is to explore how practitioners appraise the values of different outcomes and to test how this appraisal influences their decisions surrounding the so-called fidelity-adaptation dilemma. This dilemma is related to the balance between using an EBI as it was designed (to ensure its effectiveness) and making appropriate adaptations (to ensure alignment with constraints and possibilities in the local context). METHODS: This project consists of three sub-studies. The participants will be professionals leading evidence-based parental programs in Sweden and, in Sub-study 1, parents and decision-makers. Sub-study 1 will use sequential focus groups and individual interviews to explore parameters that influence fidelity and adaptation decisions-the dilemmas encountered, available options, how outcomes are valued by practitioners as well as other stakeholders, and value trade-offs. Sub-study 2 is a discrete choice experiment that will test how value appraisals influence decision-making using data from Sub-study 1 as input. Sub-study 3 uses a mixed-method design, with findings from the two preceding sub-studies as input in focus group interviews to investigate how practitioners make sense of findings from optimal decision situations (experiment) and constrained, real-world decision situations. DISCUSSION: The project will offer unique insights into decision-making processes that influence how EBIs are used in practice. Such knowledge is needed for a more granular understanding of how practitioners manage the fidelity-adaptation dilemma and thus, ultimately, how the value of EBI implementation can be optimized. This study contributes to our knowledge of what happens once EBIs are adopted-that is, the gap between the way in which EBIs are intended to be used and the way in which they are used in practice.

Professionals' management of the fidelity-adaptation dilemma in the use of evidence-based interventions-an intervention study.

BACKGROUND: Evidence-based interventions (EBIs) can be effective tools for the prevention of disease and health promotion. However, their implementation often requires a delicate balance between the need to adjust the intervention to the context in which it is implemented and the need to keep the core components that make the intervention effective. This so-called dilemma between fidelity and adaptation is often handled by health professionals in the sustainment phase of an implementation (i.e., once the intervention has been adopted and institutionalized in an organization), but not much is known about how and to what extent health professionals are affected by this dilemma. Focusing on the sustainment phase, this project aims to study (1) how fidelity and adaptation are managed by professionals using an EBI, (2) how the fidelity-adaptation dilemma affects professionals' psychosocial working conditions, and (3) how a structured decision support influences professionals' management of the dilemma and their psychosocial working conditions. METHODS: The study is set in Sweden, and the EBI in focus is a parental program (All Children in Focus). A longitudinal within-person intervention design is used, combined with a cross-sectional survey design. Data sources include web-based questionnaires, brief interviews, fidelity ratings, paper-and-pen questionnaires, and written documentation, collected at multiple time points with both group leaders and parents as respondents. DISCUSSION: This project approaches fidelity and adaptation from the perspective of the professionals that manage EBIs during the sustainment phase of implementation. Although it is well known that EBIs continue to change over time, it remains to be understood how the fidelity-adaptation dilemma can be managed so that the effectiveness of interventions is retained or improved, not diluted. Moreover, the project adds to the literature by presenting an occupational health perspective on the fidelity-adaptation dilemma. It is acknowledged that fidelity and adaptation may have consequences for not only clients but also the occupational wellbeing of the professionals managing the dilemma, and subsequently, their willingness and ability to deliver EBIs in a sustainable way.

Exploring the association between problem drinking and language use on Facebook in young adults.

Recent literature suggests that variations in both formal and content aspects of texts shared on social media tend to reflect user-level differences in demographic, psychosocial, and behavioral characteristics. In the present study, we examined associations between language use on Facebook and problematic alcohol use. We collected texts shared on Facebook by a sample of 296 adult social media users (66.9% females; mean age = 28.44 years (SD = 7.38)). Texts were mined using the closed-vocabulary approach based on the Linguistic Inquiry Word Count (LIWC) semantic dictionary, and an open-vocabulary approach performed via Latent Dirichlet Allocation (LDA). Then, we examined associations between emerging textual features and alcohol-drinking scores as assessed using the AUDIT-C questionnaire. As a final aim, we employed the Random Forest machine-learning algorithm to determine and compare the predictive accuracy of closed- and open-vocabulary features over users' AUDIT-C scores. We found use of words about family, school, and positive feelings and emotions to be negatively associated with alcohol use and problematic drinking, while words suggesting interest in sport events, politics and economics, nightlife, and use of coarse language were more frequent among problematic drinkers. Results coming from LIWC and LDA analyses were quite similar, but LDA added information that could not be retrieved only with LIWC analysis. Furthermore, open-vocabulary features outperformed closed-vocabulary features in terms of predictive power over participants' AUDIT-C scores (r = .46 vs. r = .28, respectively). Emerging relationships between text features and offline behaviors may have important implications for alcohol screening purposes in the online environment.

"Development and preliminary validation of an image-based instrument to assess depressive symptoms".

Depression has high social and economic costs, making the reducing of potential barriers to screening of utmost importance. The use of non-verbal, image-based items might help to widen accessibility to depression screenings due to their potentially increased ease of interpretation and language-free nature. In this view, the paper presents two studies exploring the feasibility of assessing depressive symptoms using a set of image-based items consisting of 36 emoji. In study 1, 430 online-recruited young adults participated to investigate whether they ever felt in the way depicted by each emoji during the last week. Results showed that 33 emoji had significant, theoretically coherent correlations with the 10-item version of the Center for Epidemiologic Studies Depression Scale. Next, a subset of 10 emoji were selected for potential inclusion in a brief depression assessment. In study 2, using a sample of 482 young adults, the 10-item emoji-based assessment showed acceptable internal consistency, and theoretically consistent convergent and divergent validity with depressive symptoms, and big-5 personality traits. Further, the emoji-based screening instrument showed remarkable accuracy in identifying individuals showing depression symptoms. Overall, results indicate that the selected emoji represent a promising alternative to text-based items when assessing depressive symptoms among young adults.

The role of the mother-child relationship in the route from child ADHD to adolescent symptoms of depressed mood.

We attempt to explain the co-variation between ADHD and symptoms of depressed mood, focusing on the family context and testing whether the mother-child relationship mediates or moderates the link between child ADHD and youth depressed mood symptoms. In a longitudinal study, we used mother and youth reports for 596 Swedish youth, 50% boys, from a community sample at 10, 15, and 18 years of age. The results did not support the mediation hypothesis. Only one moderation effect was found. Mother-child conflicts in mid-adolescence, as rated by mothers, increased symptoms of depressed mood symptoms in late adolescent only for youth with high levels of hyperactivity symptoms. However, depressed mood symptoms at age 18 were predicted by low mother-child involvement in mid-adolescence, over and above the effects of inattention symptoms. This latter finding was consistent across mother and youth ratings of the relationship. Implications of these results are discussed.

Adolescents and social support situations.

The present study concerned adolescents' needs for social support with a focus on specific situations. The Adolescent Need for Social Support Questionnaire (ANSSQ) was developed based on qualitative interviews with typically developing adolescents about situations in which they need parent support. The questionnaire was tested on a sample of 380 Swedish 15-year-olds. A 3-component structure reflecting the dimensions "Home and school", "Low mood", and "Sex and alcohol" was tested in SEM analyses. Scales based on these dimensions, measuring support from parents and peers, yielded satisfactory psychometric results. Parent support was preferred over peer support for "Home and school" situations; in the other two areas peers were more likely to be the support providers. Females turned more often to parents and friends for support than males. Seeking parental support was positively related to adolescent disclosure and negatively related to adolescent secrecy, indicating convergent and discriminant validity. Further validation of the ANSSQ is discussed. The current study points to possibilities for adapting measures of social support to contexts.

Associations of frailty and psychosocial factors with autonomy in daily activities: a cross-sectional study in Italian community-dwelling older adults.

Frailty has been recognized as a risk factor for geriatric adverse events. Little is known of the role of psychosocial factors associated with frailty in explaining negative outcomes of aging. This study was aimed at 1) evaluating the differences in psychosocial factors among robust, prefrail, and frail individuals and 2) investigating whether there was any interaction effect of frailty status with empirically identified clusters of psychosocial factors on autonomy in the activities of daily living (ADLs). Two-hundred and ten older adults (age 73±6 years, 66% women) were involved in this study. Frailty was assessed using an adapted version of the frailty phenotype. The psychosocial factors investigated were depressive symptoms using the 20-item Center for Epidemiologic Studies Depression Scale, social isolation using the Friendship Scale, and loneliness feeling using the eight-item UCLA Loneliness Scale. The autonomy in ADLs was measured with the Groningen Activity Restriction Scale. Thirty-one percent of participants were robust, 55% prefrail, and 14% frail. We performed an analysis of covariance which showed differences between robust, prefrail, and frail individuals for all the psychosocial variables: Center for Epidemiologic Studies Depression Scale, F(2, 205)=18.48, P<0.001; Friendship Scale, F(2, 205)=4.59, P=0.011; UCLA Loneliness Scale, F(2, 205)=5.87, P=0.003, controlling for age and sex. Using the same covariates, the two-way analysis of covariance indicated an interaction effect of frailty with psychosocial factors in determining ADLs, F(4, 199)=3.53, P=0.008. This study demonstrates the close relationship between frailty and psychosocial factors, suggesting the need to take into account simultaneously physical and psychosocial components of human functioning.

The Prospective Links Between Hyperactive/Impulsive, Inattentive, and Oppositional-Defiant Behaviors in Childhood and Antisocial Behavior in Adolescence: The Moderating Influence of Gender and the Parent-Child Relationship Quality.

We prospectively investigated the effect of child hyperactive/impulsive, inattentive, and oppositional/defiant behaviors on the development of youth antisocial behaviors, and the moderating influence of gender and the parent-child relationship quality in a normative sample. Participants (N = 673, 50 % girls) were assessed at 10 years of age (parent reports) and at age 15 (parent and adolescent reports). Using latent change models, we found that initial levels of, as well as increases in, hyperactivity/impulsivity and oppositional behaviors and initial levels of inattention behaviors predicted youth antisocial behaviors. The increase in oppositional behaviors was predictive of youth antisocial behaviors in girls only. Child hyperactive/impulsive behaviors predicted youth antisocial behaviors only in children for whom the quality of the parent-child relationship deteriorated from childhood to adolescence. Thus, both initial levels of and increases in disruptive behaviors as well as gender are important for understanding the development of antisocial behaviors in adolescence. We received partial support for the hypothesized, moderating role of a high-quality parent-child relationship.

A national evaluation of parenting programs in Sweden: The short-term effects using an RCT effectiveness design.

OBJECTIVE: We evaluated the effectiveness of 4 parent-training programs for children with externalizing problems. We tested the effectiveness of 3 behavioral programs (Comet, Cope, and Incredible Years) and 1 nonbehavioral program (Connect) in reducing child behavior problems and attention-deficit/hyperactivity disorder (ADHD) symptoms, in improving positive parenting and parenting competence, and in decreasing negative parenting and parents' stress and depressive symptoms. METHOD: This national study was designed as a randomized-controlled effectiveness trial (RCT). The treatments were carried out in 30 clinical and community-based practices. Parents of 908 children (ages 3-12 years) were randomly assigned to 1 of 2 parent training programs available at each practice, or to a wait-list condition, where parents had sought help from regular services. Before and after treatment, parents rated child behavior problems and parenting strategies. RESULTS: At posttreatment, children whose parents had received interventions showed a strong decrease in child conduct problems and a moderate to strong decrease in ADHD symptoms. About half of parents whose children scored over the 95th percentile on the behavior measures (Eyberg Child Behavior Inventory, Swanson, Nolan, and Pelham Rating Scale), a clinically meaningful cutoff, reported that their children were no longer above the cutoff after the intervention. Parents showed considerably less negative behaviors toward their children at posttest compared with pretest; they increased in parental competence, and decreased in both stress and depressive symptoms. Overall, the behavioral programs were more effective than the nonbehavioral program. CONCLUSIONS: The results support the general efficacy of parent training in a short-term perspective.

Europe needs a central, transparent, and evidence-based approval process for behavioural prevention interventions.

Fabrizio Faggiano and colleagues discuss how a central, transparent, and evidence-based approval process is needed for behavioral prevention interventions in Europe and propose a way forward. Please see later in the article for the Editors' Summary.

Improving dissemination of evidence-based programs through researcher-practitioner collaboration.

Prevention field has achieved major advances in developing, implementing, and testing the efficacy of preventive interventions in controlled settings. Nevertheless, there is still a gap in translating the success of programs in efficacy trials into real-life settings. Dissemination of evidence-based programs is a major challenge. The authors argue that promoting adoption of evidence-based programs requires further improvements in three areas, and collaboration between researchers and practitioners. First, there is a need to develop a holistic assessment system encompassing both risk/need and readiness assessments. Second, there is need for new methods for improving implementation quality. Third, prevention research needs to focus more on identifying the mechanisms that explain how programs work and the core elements of the program. Both researchers and practitioners have roles and opportunities to collaborate to achieve developments in these areas.

Short-term mediating factors of a school-based intervention to prevent youth substance use in Europe.

PURPOSE: To investigate factors mediating the effects of a European school-based intervention (Unplugged) based on a social influence approach to youths' substance use. METHODS: Schools in seven European countries (n = 143, including 7,079 pupils) were randomly assigned to an experimental condition (Unplugged curriculum) or a control condition (usual health education). Data were collected before (pretest) and 3 months after the end of the program (posttest). Multilevel multiple mediation models were applied to the study of effect mediation separately for tobacco, alcohol, and cannabis use. Analyses were conducted on the whole sample, and separately on baseline users and nonusers of each substance. RESULTS: Compared with the control group, participants in the program endorsed less positive attitudes toward drugs; positive beliefs about cigarettes, alcohol, and cannabis; and the normative perception of peers using tobacco and cannabis. They also increased in knowledge about all substances and refusal skills toward tobacco. Decreased positive attitudes toward drugs, increase in refusal skills, and reappraisal of norms about peer using tobacco and cannabis appeared to mediate the effects of the program on the use of substances. However, mediating effects were generally weak and some of them were only marginally significant. CONCLUSIONS: This study lends some support to the notion that school-based programs based on a social influence model may prevent juvenile substance use through the modification of attitudes, refusal skills, and normative perceptions.

Online and Offline Friendship Among Italian Adolescent Girls Following a Non-Traditional School Track.

BACKGROUND: There is still a question of whether online friendship predicts changes in face-to-face friendship (Reduction Hypothesis) or face-to-face friendship predicts changes in online friendship (Compensation Hypothesis) during adolescence. OBJECTIVE: The purpose of this study was to compare these two hypotheses to determine which comes first: online friendship or offline friendship. METHOD: Eighty adolescent girls between the ages of 14 and 19 years (mean, 16.07 years; standard deviation, 1.28 years) on a non-traditional school track completed self-report questionnaires. Two wave longitudinal models were tested with the use of cross-lagged analysis to compare the hypotheses. RESULTS: Analysis showed that negative face-to-face friendship quality predicted online friendship but that the opposite was not true. CONCLUSIONS: The study's findings underlined the compensation role of online friendship for girls with poor or unsatisfactory offline social worlds. The implications of this information and suggestions for clinicians and professionals to use to enhance adolescent social skills and to promote appropriate use of the Internet will be discussed.