Fitting anxious emotion-focused intervention into the ecology of schools: results from a test anxiety program evaluation

The impact of universal mental health screening on stigma in primary schools

BACKGROUND

Primary school students struggling with mental health are less likely than high school students to access mental health care, due to barriers such as mental health stigma and low mental health literacy among children and parents. The near universal reach of schools offers a potential avenue to increase access to mental health care through early identification. The potential risks of this approach also need to be understood. This study monitored the impact of universal screening for mental health symptoms on stigma and mental health outcomes for primary school students.

METHODS

Across 6 primary schools, a cluster randomised controlled trial allocated schools to one of two conditions. Conditions varied based on the order and frequency of symptom and stigma questionnaires. A sample of 798 children (8 to 13 years; Mage = 10.29) completed assessments at baseline, 6-week, and 12-week follow-ups.

RESULTS

Significant time-by-group interaction effects were present, indicating differing changes in mental health stigma between groups. Follow-up analyses of subscales showed significant time-by-group interaction effects for concerns around self-stigma and secrecy, but not for public stigma. The frequency and presentation order of the questionnaires impacted on mental health stigma. Initially, children reporting on mental health symptoms before stigma, reported heightened stigma, but over time, those receiving more frequent presentations of the symptom check experienced an overall stigma reduction, contrasting with an increase in the comparison group.

CONCLUSION

The frequency and presentation order of mental health symptom assessments impact children's reports of mental health stigma, underscoring the importance of screening context. Potential screening harms, such as exacerbating self-stigma and secrecy, warrant consideration. Addressing stigma-related barriers is crucial for enhancing mental health care access for children in schools. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12622001114730) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384472 Date of trial registration: 12th August 2022.

Program evaluation of a school-based mental health and wellness curriculum featuring yoga and mindfulness

BACKGROUND

Interest in the effectiveness of mindfulness-based interventions such as yoga in primary schools has grown. Evidence shows promise, as youth who engage in yoga to promote mindfulness show improved coping skills, increased socio-emotional competence and prosocial skills, academic performance, attention span, and ability to deal with stress.

OBJECTIVE

This study reports the results of a program evaluation of a universal health and wellness curriculum, Pure Power, designed to teach youth yoga techniques, mindfulness, and emotion regulation.

METHODS

A non-randomized comparison design examined outcomes among participants from schools that completed the intervention with highest fidelity of implementation (n = 461) and from students in matched comparison schools (n = 420). Standard measures of coping, emotion regulation and emotion dysregulation, spelling, and math achievement were collected.

RESULTS

Analyses suggest the youth in the intervention schools demonstrated relative improvement on measures of emotion regulation, spelling, and math.

CONCLUSIONS

Challenges in implementation in real-life settings are vital to identify. The data provide some real-world evidence for the effectiveness of a universal health and wellness curriculum on emotion regulation and positive academic outcomes. Training school staff to deliver the intervention may foster implementation. Future research should test the effectiveness of who delivers the intervention; for example, teacher-delivered groups vs. other wellness personnel.

Academic Stress Interventions in High Schools: A Systematic Literature Review

The experience of academic stress is common during high school and can have significant negative consequences for students' educational achievement and wellbeing. High school students frequently report heightened levels of school-related distress, particularly as they approach high-stakes assessments. Programs designed to reduce or prevent academic stress are needed, and their delivery in school settings is ideal to improve treatment access. The current review aimed to examine the effectiveness of high school-based programs in reducing or preventing academic stress. A systematic search returned 31 eligible studies across 13 countries. Programs were categorised according to intervention type, format, and facilitator. Results showed that the methodological quality of most studies was poor, and many used an inactive control group. As predicted by theories of academic stress, the strongest evidence was for programs grounded in cognitive-behavioural therapy (CBT). There was evidence that both universal and targeted approaches can be beneficial. The unique implementation issues for these two formats are discussed. Most programs were delivered by psychologists and were generally effective, but almost all of these were CBT programs. A smaller proportion of programs delivered by teachers were effective. Therefore, future studies should evaluate the implementation success of programs to improve the rate of effective delivery by school staff. Overall, the field will benefit from more randomised controlled trials with comparisons to active control groups, larger sample sizes and longer-term follow-ups.

The Effectiveness of School-Based Skills-Training Programs Reducing Performance or Social Anxiety: Two Randomized Controlled Trials

Background

Given that high levels of stress during adolescence are associated with negative consequences, it is important that adolescents with psychological needs are supported at an early stage, for instance with interventions at school. However, knowledge about the potential of school-based programs targeting adolescents with psychological needs, aimed at reducing school or social stress, is lacking.

Objective

The current study aimed to investigate the effectiveness of two targeted school-based skills-training programs, addressing either skills to deal with performance anxiety or social skills.

Methods

Two randomized controlled trials were performed with participants who self-selected to one of the programs. The sample comprised of N = 361 adolescents (M age = 13.99 years, SD = 0.83) from various educational levels and ethnic identity backgrounds. The performance anxiety program included N = 196 participants (N = 95 in the experimental group), while the social skills program included N = 165 participants (N = 86 in the experimental group). MANCOVA's were performed.

Results

The performance anxiety program had a small effect on reducing adolescents' test anxiety. Furthermore, for adolescents who attended more than half of the sessions, the program had small effects on reducing test anxiety and fear of failure. The program did not improve adolescents' coping skills or mental health. The social skills program was not effective in improving social skills, social anxiety, and mental health.

Conclusions

A relatively short, targeted program addressing skills to deal with performance anxiety can have the potential to reduce adolescents' performance anxiety.

Trial registration

International Clinical Trials Registry Platform (Netherlands Trial Register, number NTR7680). Registered 12 December 2018. Study protocol van Loon et al., (2019).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10566-023-09736-x.

Streamlined pediatric anxiety program for school mental health services

There needs to be serious transformation of evidence-based interventions (EBIs) into real-world solutions; otherwise, EBIs will never achieve the intended public health impact. In a randomized trial, we reported effects of a redesigned anxiety program. Herein, we described the redesign process that led to the program. Survey data revealed provider preferences for school mental health anxiety services. Focus groups and prototype feedback sessions revealed service barriers to uptake, implementation, and sustainability along with corresponding enabling strategies. Prototype feedback sessions also focused on refinement and fine-tuning of the redesign. In the end, traditional EBI strategies were transformed and packaged into six lessons, lasting 20-30 minutes each, and amenable to delivery in small-group format. The redesign achieved the intended purpose of retaining elements from cognitive and behavior therapy and social skills training for the target population of the intervention (e.g., 3rd to 5th graders with heterogeneous anxiety problems - identified and referred). The streamlined EBI is accessible from PBS LearningMedia™ - a service that hosts public, research-based, and school-ready materials.

Impact of anxiety and depression on academic achievement among underserved school children: evidence of suppressor effects

Anxiety and depression symptoms may leave children at risk for lower academic scores, though this unique linkage to academic achievement in underserved youth is less well established. This study aimed to examine how anxiety and depression are uniquely related to spelling and math achievement beyond attention and hyperactivity deficits in children in underserved schools. Children aged 8 to 11 (n = 1085, 47.3% female) from historically underserved groups (Hispanic 75.3%, American Indian 6.4%, Black 4.9%, and White 1.5%) from 13 schools across two public school districts in California participated in the assessment of emotional and behavioral health symptoms that included a spelling and math assessment. While there was no relationship between anxiety or hyperactivity on spelling and math scores, depression and attention problems were significantly negatively related to spelling and math scores. However, when entered simultaneously, evidence of suppressor effects emerged. Anxiety and hyperactivity both became positively predictive of math. Similarly, anxiety became positively predictive of spelling. Subsample analyses showed that these suppressor effects were only in females. The associations among anxiety, depression, attention, and hyperactivity with spelling and math achievement are complex, and when controlling for depression and attention, anxiety levels and hyperactivity may be motivating some level of achievement in these areas.

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one's ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.

Implementation trial of a cognitive behavioural therapy programme for reducing student stress in the final year of secondary school

The final year of secondary school has been shown to be associated with heightened student stress. Psychological interventions have been shown to be effective in reducing and preventing distress in students during this school period, although the widespread adoption of these interventions into school settings is limited. There have been recent calls for research to examine the implementation success of evidence-based programmes when used by schools in school settings. The present study aimed to evaluate the implementation success of an evidence-based cognitive-behavioural therapy programme (Study without Stress) using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. At one Australian high school, all tutor group teachers were trained by the school counsellor to deliver the programme in standard school classes to students in the lead up to their final year of secondary school. Students (n = 80) and teachers (n = 11) reported on programme success against the RE-AIM framework at pre-intervention, post-intervention, and three-month follow-up. The findings indicated that SWOS was implemented successfully by the school. SWOS was associated with maintaining student stress levels at normal levels over time, as well as reducing the severity of stress for initially highly distressed students. The findings provide evidence from implementation science that SWOS can be adapted and delivered effectively by school staff to manage stress in final year secondary school students.

Translating the neuroscience of adverse childhood experiences to inform policy and foster population-level resilience

Imaging methods have elucidated several neurobiological correlates of traumatic and adverse experiences in childhood. This knowledge base may foster the development of programs and policies that aim to build resilience and adaptation in children and youth facing adversity. Translation of this research requires both effective and accurate communication of the science. This review begins with a discussion of integrating the language used to describe and identify childhood adversity and their outcomes to clarify the translation of neurodevelopmental findings. An integrative term, Traumatic and Adverse Childhood Experiences (TRACEs+) is proposed, alongside a revised adverse childhood experiences (ACEs) pyramid that emphasizes that a diversity of adverse experiences may lead to a common outcome and that a diversity of outcomes may result from a common adverse experience. This term facilitates linkages between the ACEs literature and the emerging neurodevelopmental knowledge surrounding the effect of traumatic adverse childhood experiences on youth in terms of the knowns and unknowns about neural connectivity in youth samples. How neuroscience findings may lead directly or indirectly to specific techniques or targets for intervention and the reciprocal nature of these relationships is addressed. Potential implications of the neuroscience for policy and intervention at multiple levels are illustrated using existing policy programs that may be informed by (and inform) neuroscience. The need for transdisciplinary models to continue to move the science to action closes the article. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Streamlined Prevention and Early Intervention for Pediatric Anxiety Disorders: A Randomized Controlled Trial

There is a need to optimize the fit between psychosocial interventions with known efficacy and the demands of real-word service delivery settings. However, adaptation of evidence-based interventions (EBI) raises questions about whether effectiveness can be retained. This randomized controlled trial (RCT) evaluated a streamlined package of cognitive, behavior, and social skills training strategies known to prevent and reduce anxiety symptom and disorder escalation in youth. A total of 109 youth (Mage = 9.72; 68% girls; 54% Latinx) at risk based on high anxiety were randomized to the streamlined prevention and early intervention (SPEI) (n = 59) or control (n = 50) and were assessed at pretest, posttest, and 12-month follow-up. A main objective was to determine whether our redesign could be delivered by community providers, with acceptable levels of fidelity, quality, and impact. In terms of process evaluation results, there was high protocol fidelity, excellent clinical process skills, few protocol adaptations, and high satisfaction with the SPEI. In terms of outcomes, there were no significant main or moderated effects of the SPEI at the immediate posttest. However, at the follow-up, youth in the SPEI reported greater self-efficacy for managing anxiety-provoking situations, greater social skills, and fewer negative cognitive errors relative to controls. Collectively, findings suggest that the redesigned SPEI might be an attractive and efficient solution for service delivery settings.

Commentary on the Special Issue on Network Analysis: Assessment, Intervention, Theory, and the Nature of Reality: Actualizing the Potential of Network Perspectives on Posttraumatic Stress Disorder

This commentary on the Journal of Traumatic Stress special issue on network analysis explores the network perspective on posttraumatic stress disorder (PTSD), emphasizing the advances in research made in this collection of articles. The commentary is organized around the following themes related to actualizing the perspective's methodological, assessment, and intervention potential and the potential shift in the theoretical underpinnings of mental disorders that networks models imply. First, extant data using network analysis suggest that reactions to traumatic stress are more complicated than once thought but that this complexity does not mean efficient, relatively simple heuristics to aid assessment and intervention do not exist. Attention to methodological issues in symptom assessment may help move this aspect of the research forward. Second, the extant research is largely correlational and has not yet established causal linkages, although temporal associations underlying network models are being identified. Prospective and intervention studies employing network analysis are critical. Third, the network perspective of PTSD symptoms may advance research on the mechanisms of risk and resilience (e.g., neurodevelopmental, cognitive behavioral, emotional, and social models) by helping link symptoms to theoretical causal processes. A developmental framework that views the effect of traumatic stress in terms of temporal cascades of reactions with both negative and potentially positive cognitive, behavioral, social, and emotional outcomes fits the network analysis model. Fourth, network models call into question some of the fundamental assumptions underlying the conceptualization of mental disorders, leaving several ontological questions and implications currently unanswered; research examining the implications of the new assumptions is needed.

The effectiveness of school-based skills-training programs promoting mental health in adolescents: a study protocol for a randomized controlled study

Background

Adolescence is a period of elevated stress sensitivity, which places adolescents at increased risk of developing mental health problems such as burnout, depression, anxiety, and externalizing problems. Early intervention of psychological needs and low-threshold care addressing such needs may prevent this dysfunctional development. Schools may provide an important environment to identify and address psychological needs. The aim of this protocol is to describe the design of a study aiming to evaluate the effectiveness of low-threshold school-based skills-training programs promoting the mental health of adolescents and to examine moderators of the effectiveness.

Methods

A Randomized Controlled Trial will be conducted to examine the effectiveness of two school-based skills-training programs aiming to promote mental health by improving either skills to deal with performance anxiety or social skills. A multi-informant (i.e., students, parents, and trainers) and multi-method (i.e., questionnaires and physiological measurements) approach will be used to assess program targets (skills to deal with performance anxiety or social skills), direct program outcomes (performance or social anxiety) and mental health outcomes (i.e., stress, internalizing and externalizing problems, self-esteem and well-being), as well as specific moderators (i.e., student, parent and program characteristics, social support, perfectionism, stressful life events, perceived parental pressure, positive parenting behavior, treatment alliance and program integrity).

Discussion

The current study will provide information on the effectiveness of school-based skills-training programs. It is of crucial importance that the school environment can provide students with effective, low-threshold intervention programs to promote adolescents’ daily functioning and well-being and prevent the emergence of mental health problems that negatively affect school performance.

Trial registration

Dutch Trial Register number NL7438. Registered 12 December 2018.

Stigma related to targeted school-based mental health interventions: A systematic review of qualitative evidence

BACKGROUND

School-based mental health services have been advocated to increase access to psychological support for children and adolescents. However, concerns have been raised about the potential stigma associated with selection of students and the visibility of school-based service contact.

METHODS

This review assessed findings from qualitative studies to identify potential stigmatising effects of participation in targeted school-based mental health interventions for students attending primary- or secondary-level education. Eight articles (reflecting seven studies) were identified through electronic database searches (PsycInfo, EMBASE, Medline, CINAHL, ERIC), supplemented by citation and reference searches and expert consultations. Data were synthesised according to established guidelines for thematic synthesis.

RESULTS

Three overarching themes were identified: "anticipated and experienced stigma", "consequences of stigma" and "mitigating strategies". These findings illustrate how pervasively stigma can compromise efforts to increase access to mental health care through targeted school-based provision, while also outlining strategies endorsed by students for alleviating the risk and/or impact of stigma.

LIMITATIONS

The findings need to be considered in view of the relative scarcity of surveyed evidence. Furthermore, as all evidence came from high-income and Western countries, the applicability to other contexts is unclear.

CONCLUSIONS

This synthesis reflects the first overview of qualitative evidence regarding stigmatising experiences and concerns associated with students' engagement with targeted school-based mental health interventions. The findings should inform efforts for mitigating stigma-related barriers to students' engagement in targeted mental health support, and serve to guide future research in this area.

The Network Structure of Posttraumatic Stress Symptoms in Children and Adolescents Exposed to Disasters

OBJECTIVE

To evaluate current theoretical assumptions about the nature of pediatric posttraumatic stress disorder (PTSD) by examining the network structure of PTSD in a sample of youth exposed to disasters and testing for age differences. Network analysis provides the opportunity to identify "central" symptoms that might hold an outsized influence over others and are important targets for research and treatment. The authors hypothesized that particular symptoms would exhibit greater influence over others. They further hypothesized marked differences in symptom networks across children and adolescents.

METHOD

Participants were 786 youth 8 to 13 years old (children) and 14 to 18 years old (adolescents) exposed to Hurricanes Katrina and Gustav who were assessed for PTSD symptoms using the University of California-Los Angeles PTSD Reaction Index for Children. Network models were computed and constructed using the R-package qgraph, which estimates associations between symptoms and forms graphic network models.

RESULTS

Consistent with the hypotheses, the symptom network demonstrated meaningful variability across age, particularly in the strength of associations, and the relative importance of individual symptoms to the network as a whole. Results further demonstrated that symptoms cluster together in a manner that adds a unique perspective to current model conceptualizations.

CONCLUSION

Network analysis is a potentially important additional conceptualization of psychopathology with related data analytic techniques. Results suggest that PTSD can be characterized as a web of interactions between symptoms. This work illuminates differences in the PTSD symptom network across development, such as the link between numbness of negative affect and amnesia in children, but not in teens, and how the critical symptoms within that network differ across childhood and adolescence. Network analysis could allow the re-envisioning of the nature of this complex disorder with new avenues for research and clinical practice.

Preventing Adolescent Social Anxiety and Depression and Reducing Peer Victimization: Intervention Development and Open Trial

BACKGROUND

Social anxiety disorder (SAD) and depression are common among adolescents, frequently comorbid, and resistant to change. Prevention programs for adolescent SAD are scant, and depression prevention programs do not fully address peer-risk factors. One critical peer-risk factor for SAD and depression is peer victimization. We describe the development and initial evaluation of a transdiagnostic school-based preventive intervention for adolescents with elevated symptoms of social anxiety and/or depression and elevated peer victimization. We modified Interpersonal Psychotherapy-Adolescent Skills Training for depression, incorporating strategies for dealing with social anxiety and peer victimization.

OBJECTIVE

Our open trial assessed the feasibility, acceptability, and preliminary benefit of the modified program (called UTalk) for adolescents at risk for SAD or depression and who also reported peer victimization.

METHOD

Adolescents (N=14; 13-18 years; 79% girls; 86% Hispanic) were recruited and completed measures of peer victimization, social anxiety, and depression both pre- and post-intervention and provided ratings of treatment satisfaction. Independent evaluators (IEs) rated youths' clinical severity. The intervention (3 individual and 10 group sessions) was conducted weekly during school.

RESULTS

Regarding feasibility, 86% of the adolescents completed the intervention (M attendance=11.58 sessions). Satisfaction ratings were uniformly positive. Intention-to-treat analyses revealed significant declines in adolescent- and IE-rated social anxiety and depression and in reports of peer victimization. Additional secondary benefits were observed.

CONCLUSIONS

Although further evaluation is needed, the UTalk intervention appears feasible to administer in schools, with high satisfaction and preliminary benefit. Implications for research on the prevention of adolescent SAD and depression are discussed.