Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia.

INTRODUCTION: Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE). METHODS: Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS: TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up. CONCLUSIONS: These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies.

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12-15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.

Maternal Problem Drinking and Child Mental Health.

BACKGROUND: Offspring of individuals with alcohol use disorders have been shown to have elevated risk for mental health problems. OBJECTIVES: To examine the association between maternal problem drinking and child mental health as assessed by three informants in three European countries. METHODS: Data were drawn from the School Child Mental Health in Europe study. Maternal alcohol use was assessed using the alcohol use disorders identification test. Child mental health was assessed using the mother and teacher versions of the strengths and difficulties questionnaire, and the child self-reported Dominic interactive. Analyses were performed on 2,678 individuals, 6-11 year olds. RESULTS: Adjusting for variables associated with maternal drinking, among children eight years old or younger, excessive drinking was not significantly associated with mental health problems, whether reported by the mother, teacher or by the child. However, among girls eight years old and above, problem drinking was associated with conduct problems as reported by the mother (OR = 4.19), teacher reported total difficulties (OR = 4.69), and peer relationship problems (OR = 8.86). It was also associated with the presence of any child-reported disorder (OR = 3.88), externalizing (OR = 5.55) and internalizing disorders (OR = 4.42). Conclusions/Importance: Adjusting for sociodemographic variables and for psychological distress, maternal problem drinking was not significantly associated with child mental health problems in boys or in girls ages six to eight. The association was only present among girls ages 8-11. Examining relationships between mothers and their daughters in the peripubertal period may be a critical window for the development of effective intervention strategies.

Effectiveness of a Cognitive Behavioral Therapy-Based Indicated Prevention Program for Children with Elevated Anxiety Levels: a Randomized Controlled Trial.

Childhood anxiety is a problem not only because of its negative consequences on the well-being of children but also because of its adverse effects on society and its role in mental disorders later in life. Adequate prevention might be the key in tackling this problem. The effectiveness of Coping Cat, as an indicated CBT-based prevention program in Dutch primary school children, was assessed by means of a randomized controlled trial. In total, 141 children aged 7-13 with elevated levels of anxiety and their mothers were included and randomly assigned to an intervention group and a waiting list control group. After screening, all participants completed baseline, post-intervention, and 3-month follow-up assessments. The results showed that Coping Cat, as an indicated prevention program, reduces children's self-reported anxiety symptoms, with Cohen's effect size d of 0.66 at the 3-month follow-up. A moderating effect was found for baseline anxiety level; specifically, children with high levels of baseline anxiety who received the Coping Cat program had lower anxiety levels at follow-up compared to children with high levels of anxiety in the control condition. No moderating effects of gender or age were found. An unexpected decline in anxiety levels from screening to pre-assessment was found in both groups, and this decline was stronger in the experimental group. These promising results warrant the implementation of Coping Cat as an indicated prevention program.

Comparing the prevalence of mental health problems in children 6-11 across Europe.

BACKGROUND: Worldwide, approximately one in eight children or adolescents suffer from a mental disorder. The present study was designed to determine the cross-national prevalence of mental health problems in children aged 6-11 across seven European countries including Italy, Germany, the Netherlands, Lithuania, Bulgaria, Romania, and Turkey. METHODS: Data were collected on 7682 children for whom either parent- or teacher SDQ were completed. RESULTS: The present study provides country-specific normative banding for both parent- and teacher SDQ scores. Overall, 12.8 % of children have any probable disorder, with rates ranging from 15.5 % in Lithuania to 7.8 % in Italy, 3.8 % of children have a probable emotional disorder, 8.4 % probable conduct disorder, and 2.0 % probable hyperactivity/inattention. However, when adjusting for key sociodemographic variables and parental psychological distress, country of residence did not predict the odds of having any disorder. For specific disorders, however, country of residence does have an effect on the odds of presenting with mental health problems. CONCLUSIONS: As normative data are key in the comparison of mental health status on an international level, the present data considerably advance the possibilities of future research. Furthermore, the findings underline the importance of controlling for a number of sociodemographic and parental variables when conducting international comparisons of child mental health. In addition, the findings suggest that efforts are needed locally to assist in the detection and prevention of parental psychological distress.

Does Mother-Child Interaction Mediate the Relation Between Maternal Depressive Symptoms and Children's Mental Health Problems?

The relation between maternal depressive symptoms and children's mental health problems has been well established. However, prior studies have predominantly focused on maternal reports of children's mental health problems and on parenting behavior, as a broad and unilateral concept. This cross-sectional study examined specific observed mother-child interaction behaviors through which maternal depressive symptoms are assumed to affect children's mental health problems. We expected higher rates of maternal depressive symptoms to predict higher rates of children's mental health problems, and we expected this relation to be mediated by low maternal warmth and high maternal psychological control. The sample consisted of 111 mother-child dyads referred for treatment. The mother-child interaction behaviors were coded according to the observed mother-child interaction tasks. Children's mental health problems were assessed using both maternal reports and children's self-reports. As expected, the results showed that maternal depressive symptoms were strongly related to maternal reports of children's internalizing and externalizing mental health problems. Surprisingly, maternal depressive symptoms were unrelated to children's self-reported depressive symptoms. Furthermore, mother-child interactions did not mediate the relation between maternal depressive symptoms and child mental health problems. Maternal depressive symptoms were associated with high maternal warmth, and high psychological control was associated with high levels of mother-reported externalizing mental health problems in children. These results partially replicate previous findings but add to these by using observational methods and multi-informant data. The importance of using a multi-informant and multi-method approach in assessing children's mental health problems in clinical practice and research are discussed.

Is time spent playing video games associated with mental health, cognitive and social skills in young children?

BACKGROUND: Video games are one of the favourite leisure activities of children; the influence on child health is usually perceived to be negative. The present study assessed the association between the amount of time spent playing video games and children mental health as well as cognitive and social skills. METHODS: Data were drawn from the School Children Mental Health Europe project conducted in six European Union countries (youth ages 6-11, n = 3195). Child mental health was assessed by parents and teachers using the Strengths and Difficulties Questionnaire and by children themselves with the Dominic Interactive. Child video game usage was reported by the parents. Teachers evaluated academic functioning. Multivariable logistic regressions were used. RESULTS: 20 % of the children played video games more than 5 h per week. Factors associated with time spent playing video games included being a boy, being older, and belonging to a medium size family. Having a less educated, single, inactive, or psychologically distressed mother decreased time spent playing video games. Children living in Western European countries were significantly less likely to have high video game usage (9.66 vs 20.49 %) though this was not homogenous. Once adjusted for child age and gender, number of children, mothers age, marital status, education, employment status, psychological distress, and region, high usage was associated with 1.75 times the odds of high intellectual functioning (95 % CI 1.31-2.33), and 1.88 times the odds of high overall school competence (95 % CI 1.44-2.47). Once controlled for high usage predictors, there were no significant associations with any child self-reported or mother- or teacher-reported mental health problems. High usage was associated with decreases in peer relationship problems [OR 0.41 (0.2-0.86) and in prosocial deficits (0.23 (0.07, 0.81)]. CONCLUSIONS: Playing video games may have positive effects on young children. Understanding the mechanisms through which video game use may stimulate children should be further investigated.

Reliability, factor structure, and measurement invariance of the Dominic Interactive across European countries: Cross-country utility of a child mental health self-report.

Large-scale international surveys are important to globally evaluate, monitor, and promote children's mental health. However, use of young children's self-reports in these studies is still controversial. The Dominic Interactive, a computerized DSM-IV-based child mental health self-report questionnaire, has unique characteristics that may make it preeminently appropriate for usage in cross-country comparisons. This study aimed to determine scale score reliabilities (omega) of the Dominic Interactive in a sample of 8,135 primary school children, ages 6-11 years old, in 7 European countries, to confirm the proposed 7-scale factor structure, and to test for measurement invariance of scale and item scores across countries. Omega reliability values for scale scores were good to high in every country, and the factor structure was confirmed for all countries. A thorough examination of measurement invariance provided evidence for cross-country test score comparability of 5 of the 7 scales and partial scale score invariance of 2 anxiety scales. Possible explanations for this partial invariance include cross-country differences in conceptualizing items and defining what is socially and culturally acceptable anxiety. The convincing evidence for validity of score interpretation makes the Dominic Interactive an indispensable tool for cross-country screening purposes. (PsycINFO Database Record

Country-level and individual correlates of overweight and obesity among primary school children: a cross-sectional study in seven European countries.

BACKGROUND: The present study aims to estimate childhood overweight and obesity prevalence and their association with individual and population-level correlates in Eastern and Western European countries. METHODS: Data were obtained from the School Children Mental Health in Europe, a cross-sectional survey conducted in 2010 in Italy, Germany, the Netherlands, Romania, Bulgaria, Lithuania and Turkey. The sample consists of 5,206 school children aged 6 to 11 years old. Information on socio-demographics, children's height and weight, life-style and parental attitude were reported by the mothers. Country-level indicators were obtained through several data banks. Overweight and obesity in children were calculated according to the international age and gender-specific child Body Mass Index cut-off points. Multivariable logistic regression models included socio-demographic, lifestyle, mothers' attitude, and country-level indicators to examine the correlates of overweight. RESULTS: Overall prevalence was 15.6% (95% CI = 19.3-21.7%) for overweight and 4.9% (95% CI = 4.3-5.6%) for obesity. In overweight (including obesity), Romanian children had the highest prevalence (31.4%, 95% CI = 28.1-34.6%) and Italian the lowest (10.4%, 95% CI = 8.1-12.6%). Models in the pooled sample showed that being younger (aOR = 0.93, 95% = CI 0.87-0.97), male (aOR = 1.24, 95% CI = 1.07-1.43), an only child (aOR = 1.40, 95% CI = 1.07-1.84), spending more hours per week watching TV (aOR = 1.01, 95% CI =1.002-1.03), and living in an Eastern Country were associated with greater risk of childhood overweight (including obesity). The same predictors were significantly associated with childhood overweight in the model conducted in the Eastern region, but not in the West. Higher Gross Domestic Product and Real Domestic Product, greater number of motor and passenger vehicles, higher percentage of energy available from fat, and more public sector expenditure on health were also associated with lower risk for childhood overweight after adjusting for covariables in the pooled sample and in the east of Europe, but not in the West. CONCLUSIONS: Prevalence rates of overweight and obesity in school children is still high, especially in Eastern regions, with some socio-demographic factors and life-styles associated with being overweight. It is also in the Eastern region itself where better macro-economic indicators are related with lower rates of childhood overweight. This represents a public health concern that deserves special attention in those countries undertaking economic and political transitions.

Integrating children with psychiatric disorders in the classroom: a systematic review.

BACKGROUND: The school setting may be the optimal context for early screening of and intervention on child mental health problems, because of its large reach and intertwinement with various participants (child, teacher, parent, other community services). But this setting also exposes children to the risk of stigma, peer rejection and social exclusion. This systematic literature review investigates the efficacy of mental health interventions addressed to children and adolescents in school settings, and it evaluates which programs explicitly take into account social inclusion indicators. METHOD: Only randomized controlled trials conducted on clinical populations of students and carried out in school settings were selected: 27 studies overall. Most studies applied group Cognitive Behavioural Therapy or Interpersonal Psychotherapy. RESULTS: Findings were suggestive of the effectiveness of school-based intervention programs in reducing symptoms of most mental disorders. Some evidence was found about the idea that effective studies on clinical populations may promote the social inclusion of children with an ongoing mental disorder and avoid the risk of being highly stigmatized. CONCLUSION: School programs are still needed that implement standardized models with verifiable and evidence-based practices involving the whole school community.

The School Children Mental Health in Europe (SCMHE) Project: Design and First Results.

Background : The School Children Mental Health in Europe (SCMHE) project aims to build up a set of indicators to collect and monitor children's mental health in an efficient and comparable methodology across the EU countries. It concerns primary schools children aged 6 to 11 years a range where few data are available whereas school interventions are promising. Methods : Three informants were used: parents, teachers and children. In selecting instruments language, instruments were selected according to the easiness to translate them: SDQ (Strengths and Difficulties Questionnaire) for parents and teachers and DI (Dominic Interactive). A two-step procedure was used: schools randomization then six children by class in each grade. Results : 9084 children from seven countries (Italy, Netherlands, Germany, Romania, Bulgaria, Lithuania, and Turkey) completed the Dominic Interactive in their own language. 6563 teachers and 6031 parents completed their questionnaire, and a total of 5574 interviews have been completed by the 3 informants. The participation rate of the children with parents in the participating schools was about 66.4%. As expected teachers report more externalised problems and less internalised problems than parents. Children report more internalised problems than parents and teachers. Boys have consistently more externalised problems than girls and this is the reverse for internalised problems. Combining the diverse informants and impairment levels children with problems requiring some sort of mental health care were about 9.9%: 76% did not see any mental health professional: 78.7% In Eastern countries 63.1% in Western Europe.

Suicidal ideation and mental health disorders in young school children across Europe.

INTRODUCTION: The aim of this study is to measure the prevalence of suicidal ideation and thoughts of death in elementary school children in a European survey and to determine the associated socio-demographic and clinical factors. METHODS: Data refer to children aged 6-12 (N=7062) from Italy, Turkey, Romania, Bulgaria, Lithuania, Germany, and the Netherlands randomly selected in primary schools. Suicidal thoughts and death ideation were measured using a computerized pictorial diagnostic tool from the Dominic Interactive (DI) completed by the children. The Strengths and Difficulties Questionnaire (SDQ) was administrated to teachers and parents along with a socio-demographic questionnaire. RESULTS: Suicidal ideation was present in 16.96% of the sample (from 9.9 in Italy to 26.84 in Germany), death thoughts by 21.93% (from 7.71% in Italy to 32.78 in Germany). SI and DT were more frequent in single-parent families and large families. Externalizing disorders were strongly correlated with SI and DT after controlling for other factors and this was true for internalizing disorders only when reported by the children. CONCLUSION: Recognizing suicidal ideation in young children may be recommended as part of preventive strategies such as screening in the context of the presence of any mental health problems whether externalizing or internalizing.

Parental use of corporal punishment in Europe: intersection between public health and policy.

Studies have linked the use of corporal punishment of children to the development of mental health disorders. Despite the recommendation of international governing bodies for a complete ban of the practice, there is little European data available on the effects of corporal punishment on mental health and the influence of laws banning corporal punishment. Using data from the School Children Mental Health Europe survey, the objective of this cross-sectional study was to examine the prevalence and legal status of corporal punishment across six European countries and to evaluate the association between parental use of corporal punishment and children's mental health. The study found that odds of having parents who reported using occasional to frequent corporal punishment were 1.7 times higher in countries where its use is legal, controlling for socio-demographic factors. Children with parents who reported using corporal punishment had higher rates of both externalized and internalized mental health disorders.

Maternal smoking and offspring inattention and hyperactivity: results from a cross-national European survey.

In utero exposure to tobacco smoke is associated with adverse neonatal outcomes; the association with later childhood mental health outcomes remains controversial. We used a strategy involving comparison of maternal and paternal smoking reports in a sample pooling data from six diverse European countries. Data were drawn from mother (N = 4,517) and teacher (N = 4,611) reported attention deficit and hyperactivity disorder (ADHD) symptoms in school children aged 6-11 in Turkey, Romania, Bulgaria, Lithuania, Germany, and the Netherlands, surveyed in 2010. Mothers report on self and husband's smoking patterns during the pregnancy period. Logistic regression used with control covariates including demographics, maternal distress, live births, region, and post-pregnancy smoking. In unadjusted models, maternal prenatal smoking was associated with probable ADHD based on mother [Odds Ratio (OR) = 1.82, 95 % Confidence Interval (CI) 1.45-2.29], teacher (OR = 1.69, 95 % CI 1.33-2.14) and mother plus teacher (OR = 1.49, 95 % CI 1.03-2.17) report. Paternal prenatal smoking was similarly associated with probable ADHD in unadjusted models. When controlled for relevant confounders, maternal prenatal smoking remained a risk factor for offspring probable ADHD based on mother report (OR = 1.44, 95 % CI 1.06-1.96), whereas the effect of paternal prenatal smoking diminished (e.g., mother report: OR = 1.17, 95 % CI 0.92-1.49). Drawing on data from a diverse set of countries across Europe, we document that the association between maternal smoking and offspring ADHD is stronger than that of paternal smoking during the pregnancy period and offspring ADHD. To the extent that confounding is shared between parents, these results reflect a potential intrauterine influence of smoking on ADHD in children.

The health consequences of child mental health problems and parenting styles: unintentional injuries among European schoolchildren.

OBJECTIVE: Unintentional injury is the leading cause of death for schoolchildren. We assessed the association between externalizing psychopathology, parenting style, and unintentional injury in European children in the community. METHODS: Data were drawn from the School Children Mental Health in Europe project and included 4517 schoolchildren across seven diverse European regions. Past-year injuries serious enough to seek medical attention were reported by mothers. Child mental health problems were assessed using validated measures and reported by the mothers, teachers, and children. Parenting styles were based on The Parenting Scale and the Parent Behaviors and Attitudes Questionnaire. RESULTS: Children with attention-deficit/hyperactivity symptoms and oppositional defiant symptoms had a higher risk of injury compared to other children whether based on parent report (OR=1.47, 95% C.I. 1.2-1.9), teacher report (OR=1.36, 95% C.I. 1.1-1.7), or parent and teacher report combined (OR=1.53, 95% C.I. 1.1-2.1). Children who self-reported oppositional symptoms also had higher risk of injury (OR=1.6, 95% C.I. 1.1-2.4). Low-caring behavior of parents increased the risk of injury (OR=1.4, 95% C.I. 1.1-1.9). CONCLUSION: Unintentional injury is a potential adverse health consequence of child externalizing problems. Interventions to improve parent-child relationships and prevention as well as focused treatment for externalizing problems may reduce the burden of injury.

Effectiveness and underlying mechanisms of a group-based cognitive behavioural therapy-based indicative prevention program for children with elevated anxiety levels.

BACKGROUND: Anxiety is a problem for many children, particularly because of its negative consequences not only on the wellbeing of the child, but also on society. Adequate prevention and treatment might be the key in tackling this problem. Cognitive behavioural therapy (CBT) has been found effective for treating anxiety disorders. "Coping Cat" is one of the few evidence-based CBT programs designed to treat anxiety symptoms in children. The main aim of this project is to conduct a Randomized Controlled Trial (RCT) to evaluate the effectiveness of a Dutch version of Coping Cat as an indicative group-based prevention program. The second aim is to gain insight into the mechanisms underlying its effectiveness. METHODS/DESIGN: Coping Cat will be tested in Dutch primary school children grades five through eight (ages 7 to 13) with elevated levels of anxiety. This RCT has two conditions: 130 children will be randomly assigned to the experimental (N=65, Coping Cat) and control groups (N=65, no program). All children and their mothers will be asked to complete baseline, post intervention, and 3-month follow-up assessments. In addition, children in both the experimental and control group will be asked to complete 12 weekly questionnaires matched to the treatment sessions. Main outcome measure will be the child's anxiety symptoms level (SCAS). Four potential mediators will be examined, namely active coping, positive cognitive restructuring, self efficacy and cognitions about ones coping ability (from now on coping cognitions). DISCUSSION: It is hypothesized that children in the experimental condition will experience reduced levels of anxiety in comparison with the control group. Further, active coping, positive cognitive restructuring, and coping cognitions are expected to mediate program effectiveness. If Coping Cat proves effective as a prevention program and working mechanisms can be found, this group-based approach might lead to the development of a cost-effective program suitable for prevention purposes that would be easily implemented on a large scale. TRIAL REGISTRATION: Nederlands Trial Register NTR3818.

Parental smoking in the vicinity of children and tobacco control policies in the European region.

OBJECTIVE: To ascertain patterns of parental smoking in the vicinity of children in Eastern and Western Europe and their relation to Tobacco Control Scale (TCS) scores. METHODS: Data on parental smoking patterns were obtained from the School Child Mental Health Europe (SCMHE), a 2010 cross-sectional survey of 5141 school children aged 6 to 11 years and their parents in six countries: Germany, Netherlands, Lithuania, Romania, Bulgaria and Turkey ranked by TCS into three level categories toward tobacco control policies. RESULTS: A slightly higher proportion of Eastern compared to Western European mothers (42.4 vs. 35.1%) were currently smoking in but the difference was not statistically significant after adjusting for maternal age and maternal educational attainment. About a fifth (19.3%) and a tenth (10.0%) of Eastern and Western European mothers, respectively, smoked in the vicinity of their children, and the difference was significant even after adjustment for potential confounders (p<0.001). Parents with the highest educational attainment were significantly less likely to smoke in the vicinity of their children than those with the lowest attainment. After control of these covariates lax tobacco control policies, compared to intermediate policies, were associated with a 50% increase in the likelihood of maternal smoking in the vicinity of children adjusted odds ratio (AOR) = 1.52 and 1.64. Among fathers, however, the relationship with paternal smoking and TCS seems more complex since strict policy increases the risk as well AOR = 1,40. Only one country, however belongs to the strict group. SIGNIFICANCE: Tobacco control policies seem to have influenced maternal smoking behaviors overall to a limited degree and smoking in the vicinity of children to a much greater degree. Children living in European countries with lax tobacco control policies are more likely to be exposed to second hand smoking from maternal and paternal smoking.

Effectiveness of a cognitive-behavioral therapy (CBT) manualized program for clinically anxious children: study protocol of a randomized controlled trial.

BACKGROUND: In the Netherlands, the prevalence of anxiety disorders is 20%; and children with anxiety are at increased risk for psychopathology throughout adulthood. Recently, a revised version of a cognitive behavioral therapy manualized program called 'Thinking + Doing = Daring' (TDD) was developed for children between 8 and 12 years old with an anxiety disorder. The main aim of this project is to conduct a Randomized Controlled Trial (RCT) to evaluate the effectiveness of TDD. METHODS/DESIGN: The CBT program will be tested with a RCT with 120 clinically anxious children (8-12 years old) referred to one of three mental health care agencies. Children will be randomly assigned to the experimental (N = 60, TDD) or to the control condition (N = 60, treatment as usual). The primary outcome measure will be the child's anxiety symptoms level. Secondary outcome measures will be externalizing (e.g. aggression) and internalizing problems (e.g. depression). Two potential mediators of change will be examined in the current study: therapeutic alliance and parenting. Mother and child in both the experimental and control condition will be surveyed at baseline, post treatment and after 6 and 12 months (follow-up). It is hypothesized that children in the experimental condition will show a stronger decrease in anxiety symptoms compared to children that receive treatment as usual. Moreover, we expect that a strong therapeutic alliance and decreases in parental control and rejection will contribute to treatment success. DISCUSSION: Early treatment for anxiety problems has the potential to not only result in anxiety reductions, but also to prevent future problems such as substance abuse and psychopathology throughout adulthood. Our results will be immediately relevant to practice, since we are partnering with 'real world' community agencies. If the CBT program proves more effective than treatment as usual, it could be implemented in community mental health care agencies across the Netherlands and beyond. Moreover, it has the potential to make treatment in these community settings shorter, more efficient and therefore cost-effective. TRIAL REGISTRATION: Nederlands Trial Register NTR2967.

A randomized controlled trial testing the effectiveness of a universal school-based depression prevention program 'Op Volle Kracht' in the Netherlands.

BACKGROUND: The incidence of depressive symptoms increases during adolescence, from 10.0% to 24.5% at age 11 to 15, respectively. Experiencing elevated levels of depressive symptoms increases the risk of a depressive disorder in adulthood. A universal school-based depression prevention program Op Volle Kracht (OVK) was developed, based on the Penn Resiliency Program, aimed at preventing the increase of depressive symptoms during adolescence and enhancing positive development. In this study the effectiveness of OVK will be tested and possible mediators of program effects will be focus of study as well. METHOD: The effectiveness of OVK will be tested in a randomized controlled trial with two conditions, intervention (OVK) and control condition (care as usual). Schools are randomly assigned to research conditions. OVK will be incorporated in the school curriculum, maximizing program attendance. OVK consists of 16 lessons of 50 min, given by trained psychologists to groups of 11-15 students. OVK contains Cognitive Behavioral Therapy, social skills training, problem solving and decision making. Outcomes are measured at 6, 12, 18 and 24 months follow up, to monitor long term program effects. Primary outcome is level of depressive symptoms, secondary outcomes are: anxiety, hopelessness, cognitive bias, substance use, truancy, life satisfaction, coping, self-efficacy, optimism, happiness, friendship, school performance and school attitude. The questionnaires for students will be administered in the school setting. Parents will complete a questionnaire at baseline only. DISCUSSION: In this paper the study into the effectiveness of the depression prevention program OVK was described. It is expected that OVK will prevent the increase in depressive symptoms during adolescence and enhance positive development in the intervention condition, compared to the control condition. If OVK will be effective, it can be implemented in the school context by which numerous adolescents can be reached. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2879.