Background: Difficulties with anxiety among children and young people are common and can impact upon their developmental trajectory leading to adverse outcomes in later life. There is, therefore, a need to increase access to early intervention services. Existing research has indicated that school-based cognitive behavioural interventions are effective for children and young people experiencing difficulties with anxiety, yet there remains a proportion of the population for whom they are not effective. In addition, there is a lack of research on how these may be implemented in real world settings as opposed to a research trial. The present research focuses on the provision of cognitive behavioural school-based interventions in two parts: a systematic review of psychological, interpersonal and social variables as predictors, mediators and moderators of mental health outcomes following a school-based intervention and an empirical mixed methods evaluation of the facilitators and barriers to the implementation of a school-based intervention. Method: A systematic search of electronic databases for studies examining interpersonal, psychological and social predictors, moderators and mediators of mental health outcome following school-based cognitive behavioural interventions was conducted. Effect sizes for these analyses were calculated and the quality of eligible studies was assessed using a standardised rating tool. Within the empirical project, the implementation of a school-based cognitive behavioural intervention was evaluated through a mixed methods approach. Semi-structured interviews with stakeholders in the intervention were analysed using grounded theory integrated with framework analysis. Quantitative data on the reach of the intervention, practitioner evaluation of training and coaching as well as routine outcome measures from children and young people receiving the intervention was collected. Results: Within the systematic review, twenty-two studies (N=22) met the predefined eligibility criteria. There was heterogeneity in the variables explored, effect size of these on treatment outcome and the quality of the literature within the included studies. Cognitive style was found to mediate treatment outcome, but there was limited evidence for other predictors, mediators and moderators of treatment outcome within the review. Quantitative results of the empirical project indicated that the model of the intervention was acceptable to both practitioners and children and young people, and preliminary data indicated a significant improvement in mental health outcomes. Facilitators that emerged from qualitative data included an enabling context, therapeutic engagement, motivation and congruence, self-efficacy and containment and encouragement. The exclusivity of the intervention, a lack of systemic understanding and transparency as well as demands and pressure on resources were barriers to implementation. Conclusions: Although preliminary evidence for potential predictors, mediators and moderators is presented, further research with improvements in the design and reporting of explanatory variables on treatment outcome is required prior to informing clinical decision-making. The successful implementation of school-based interventions requires multi-agency integration and collaboration as well as on-going support in managing systemic pressures and skill development.

The studies presented in this thesis sought to investigate a number of developmental factors that influence the efficacy of preventive intervention for child anxiety disorders. Preventive intervention has emerged as a vital step forward in clinical research following data indicating anxiety disorders are among the most common forms of psychopathology in youngsters (Kashani & Orvaschel, 1990; Mattison, 1992). Several risk and protective factors associated with childhood anxiety disorders have been identified, along with effective treatment protocols (Kendall, 1994; Howard & Kendall, 1996; Barrett, 1998, 1999; Silverman et al., 1999a, 1999b), as prerequisites to the development of preventive programs for child anxiety problems (Spence, 2001). The first objective of this research was to add to the literature on risk and protective factors by investigating the role of peer interaction in the development of child anxiety problems. Study one examined developmental differences in the influence of peer interaction on children's anxiety-related cognition and behaviour. One hundred and sixty two children enrolled in grade 6 (n = 96) aged between 9 and 10 years, and grade 9 (n = 66) aged between 14 and 16 years participated in the study. Participants were stratified into either an at risk group or to a healthy group, based on their anxiety scores on the Spence Child Anxiety Scale (SCAS; Spence, 1997), and further allocated to a peer group comprising of 3 'healthy' (non-anxious) and 3 'at risk' (high anxious) children. Prior to and following a peer discussion, participants completed a standardised self-report measure of threat interpretation and response plans to two ambiguous vignettes (Barrett, Rapee, Dadds, & Ryan, 1996; Dadds, Barrett, Rapee, & Ryan, 1996). Results showed all participants evidenced changes in threat interpretation and response plans following the discussion with peers (p < .001). Overall, findings highlight the potential importance of peer interaction in the development of anxiety-related cognition and behaviour. The findings of study one have important implications for the future development of school-based intervention programs; specifically those conducted in the classroom. Study two sought to advance the current research on preventive intervention for child anxiety by establishing the age at which youngsters benefit the most from the FRIENDS program as a classroom-based universal intervention. Study two presents the results of a longitudinal study evaluating the effects of a universal school-based intervention for child anxiety at two developmental stages. The study involved a cohort of 733 children enrolled in grade 6 (n = 336, 45.6%) aged between 9 and 10 years, and grade 9 (n = 401, 54.4%) aged between 14 and 16 years, Participants were allocated to either a school-based cognitive behavioural intervention or to a monitoring group. Participants completed standardised measures of anxiety, depression and coping style. Participants identified as 'at risk' of an anxiety disorder were assessed for a clinical diagnosis with a structured diagnostic interview. Results indicated the universal intervention effective in significantly reducing anxiety (p < .001), depression (p < .001) and behaviour avoidance in children at post- intervention and 12-month follow-up intervals. Grade 6 children reported significantly higher anxiety at pre-intervention and greater reductions in anxiety at post intervention compared with the grade 9 (p < .001), although both primary and secondary school participants showed equal reductions in anxiety at 12-month follow up. Overall, findings suggest universal intervention potentially successful in reducing symptoms of anxiety and increasing coping skills in children. Primary school children reported the greatest changes in anxiety symptoms, suggesting earlier preventive intervention potentially more advantageous than later intervention. Developmental differences in anxiety, depression and coping strategies are discussed in addition to the implications and limitations of this study and directions for future research.

Research shows that anxiety disorders are common and problematic in children. Treatment studies demonstrate that cognitive-behavioural interventions for children can successfully minimise these problems. Further, when implemented as early intervention or prevention programs, these interventions can prevent the onset of anxiety problems in 7 to 14 year olds and reduce existing levels of anxiety. This type of preventive approach has enormous potential for improving community mental health in a low cost model of service delivery. Yet, to develop this as a viable service model, these programs need to be evaluated under 'real world' conditions as opposed to specialist university clinical teams. In this research, the long-term effectiveness of an ecological model of the prevention of anxiety disorders for children was conducted. In the first study, teachers (N = 17) were trained intensively in the principles of anxiety and the FRIENDS anxiety prevention program (Barrett, Lowry-Webster & Holmes, 1999). Measures were taken of the PROXIMAL effects of training on the knowledge and self-efficacy of participating teachers at two points in time. Compared to teachers in a control group (N= 17) and a group comprised of psychologists regarded as experts in the FRIENDS anxiety program (N= 22), trained teachers demonstrated significant increases in the levels of knowledge and self-efficacy at time two. These increases approached levels exhibited by experts in terms of knowledge, and were not significantly different from experts in their levels of self-efficacy to implement the FRIENDS program following training. This study also explored the quality or fidelity of program implementation by these trained teachers (INTERMEDIATE EFFECTS). Results demonstrated that trained teachers implemented the program with high levels of integrity in accordance with the FRIENDS intervention manual. The second study sought to investigate the outcomes for participating children in terms of actually preventing and reducing existing levels of anxiety. Also of interest was the impact this intervention had on levels of depression. Participants were 594 children aged 10-13 years from 7 schools in Brisbane Australia. Children, and parents reported on children's social, emotional and behavioural characteristics at three-assessment points over 12 months. Results were examined universally (for all children) and for children who scored above the clinical cut-off for anxiety at pre-test. Results revealed that children in the FRIENDS intervention group reported fewer anxiety symptoms regardless of their risk status at posttest. In terms of reported levels of depression, only the high anxiety group who completed the FRIENDS intervention evidenced significant improvements at posttest. The results indicated that intervention gains were maintained over a period of 12 months, as measured by self-reports and diagnostic interviews. Moreover, evidence of a prevention effect was also demonstrated, with a significantly greater percentage of children in the control group progressed to "at risk" or "remained at risk" compared to children in the intervention group. Additionally, 85% of children in the intervention group who were scoring above the clinical cut-off for anxiety and depression were diagnosis free in the intervention condition at 12-month follow-up, compared to only 31.2% of children in the control group. Implications of these findings are examined, alongside limitations of the study and directions for future research.

Despite increasing prevalence, significant negative biopsychosocial consequences, and few treatment options, overweight and obesity in adolescence has received very little attention in the scientific literature. The major objective of this research program was to evaluate the efficacy of a cognitive behavioural (CBT) program in the treatment of adolescent overweight and obesity. Sixty three overweight or obese adolescents (28M, 35F) aged 11.5 to 18.9 years (M = 14.41, SD = 1.85) participated in a randomized controlled trial evaluating the efficacy of a CBT weight loss intervention. This comprehensive intervention program incorporated a range of CBT techniques aimed at assisting adolescents to establish and maintain healthy eating and physical activity habits. Treatment resulted in improved body composition post treatment and sustained or improved body composition following maintenance. Participation in a motivational interview (MI) prior to this CBT intervention did not influence treatment outcomes. Despite reductions in weight and body fat, lean body mass was not affected by the intervention, thus, treatment did not detrimentally effect linear growth and lean body tissue. Poor compliance with measurement protocols limits conclusions that can be drawn regarding the impact of treatment on eating and activity habits. However, results suggest that treatment resulted in a reduction in fat consumption, reduced saturated fat intake, and reduced time spent in sedentary activities. Increases in physical activity were not evident. The treatment seeking sample did not report elevated psychopathology levels and treatment did not impact on adolescent depression, anxiety, or stress. Adolescents receiving treatment reported improvements in disordered eating relative to those in the control condition. A secondary aim of this research program was to redress the limited information available on the behavioural and psychosocial factors associated with adolescent overweight and obesit y. These factors were explored in community samples of adolescents (n = 161, M = 16.3, SD = I .8) and their parents, and young adults (n = 292, M = 19.7, SD = 2.0). In comparison to both normal and overweight adolescents, treatment seeking adolescents reported greater body dissatisfaction and weight. discontent. Body weight was not associated with psychopathology in the community samples and treatment seeking adolescents did not differ from normal or overweight adolescents from the community sample in terms of psychopathology. However, young adults who reported being overweight during childhood reported greater psychopathology as young adults. These findings suggest that excess weight in adolescence may have longer term rather than immediate effects on psychopathology. A number of family factors were associated with body weight in both adolescents and young adults. Combined, results indicated that CBT is efficacious in the treatment of overweight and obesity in adolescents and MI does not improve the efficac y of CBT. The current findings suggest that the impact of excess weight on psychosocial functioning is limited to body discontent and dissatisfaction in adolescence but is associated with increased psychopathology in early adulthood. Results also highlighted the importance of parents and family in the treatment of overweight and obesity in adolescents.

<p>The aim of this thesis was to explore the prevalence of parentally experienced infant sleep problems, with special interest in severe problems, in a total community sample of 2 518 infants aged between 6 and 18 months. Factors associated with severe sleep problems were sought. Parents reported 16 % of the infants to have difficulties in falling asleep at night, and 30 % to have frequent night waking. Severe sleep problems were associated with frequent night meals, psychosocial problems in the family, exhaustion and depression in the mother, and parental stress. An association with infant difficultness, high activity and problematic behaviour was also found. </p><p>In a five-year prospective study a group of children fulfilling specific criteria for severe sleep problems in infancy (N=27) was followed after an interventional sleep programme and compared with a control group regarding sleep characteristics, behaviour and development. One month after an interdisciplinary treatment programme, combining behavioural technique with family work, the average number of times the case babies woke up had diminished from 6.0 to 1.8 times per night. A 92 % rate of improvement was reported.</p><p>The changes were stable over time. Comparisons with the controls during five years revealed no significant group difference in sleep characteristics. Concerning behaviour and development, however, there were significant differences. At the age of 5.5 years, seven of the children in the former sleep problem group met the criteria for the diagnosis of attention-deficit/hyperactivity disorder. No control child qualified for the diagnosis.</p>

The aim of this thesis was to explore the prevalence of parentally experienced infant sleep problems, with special interest in severe problems, in a total community sample of 2 518 infants aged between 6 and 18 months. Factors associated with severe sleep problems were sought. Parents reported 16 % of the infants to have difficulties in falling asleep at night, and 30 % to have frequent night waking. Severe sleep problems were associated with frequent night meals, psychosocial problems in the family, exhaustion and depression in the mother, and parental stress. An association with infant difficultness, high activity and problematic behaviour was also found. In a five-year prospective study a group of children fulfilling specific criteria for severe sleep problems in infancy (N=27) was followed after an interventional sleep programme and compared with a control group regarding sleep characteristics, behaviour and development. One month after an interdisciplinary treatment programme, combining behavioural technique with family work, the average number of times the case babies woke up had diminished from 6.0 to 1.8 times per night. A 92 % rate of improvement was reported. The changes were stable over time. Comparisons with the controls during five years revealed no significant group difference in sleep characteristics. Concerning behaviour and development, however, there were significant differences. At the age of 5.5 years, seven of the children in the former sleep problem group met the criteria for the diagnosis of attention-deficit/hyperactivity disorder. No control child qualified for the diagnosis.

Hintergrund: Prävalenzdaten weisen auf einen hohen therapeutischen Versorgungsbedarf für sexuelle Dysfunktionen hin. Unser Ziel war es zu untersuchen, inwieweit ein solcher Bedarf bei Patienten einer psychotherapeutischen Hochschulambulanz besteht und inwieweit die sexuellen Probleme von vorwiegend in Ausbildung befindlichen Verhaltenstherapeuten erkannt und therapeutisch aufgegriffen werden. Patienten und Methoden: In einer Patientenstudie (Studie 1) wurden 173 Psychotherapiepatienten (16–64 Jahre, 71,7% Frauen) mittels des Kurzfragebogens Sexualität und Partnerschaft (KFSP) zu ihrem sexuellen Interesse, ihrer sexuellen Erregungsfähigkeit, ihrer Orgasmusfähigkeit, ihrer Erektionsbzw. Lubrikationsfähigkeit sowie ihrer sexuellen Zufriedenheit im letzten Monat befragt. In der Therapeutenstudie (Studie 2) wurde untersucht, ob 16 vorwiegend in Ausbildung befindliche Therapeuten Patienten mit bzw. ohne sexuelle Dysfunktion als solche erkennen und die Probleme thematisieren und behandeln. Ergebnisse: Je nach Problembereich äußert jede zweite bis dritte Frau bzw. jeder dritte bis fünfte Mann sexuelle Probleme. Therapeuten erkennen sexuelle Schwierigkeiten bei jedem zweiten Betroffenen. Sexualität wird bei jedem zweiten Patienten thematisiert. Jede dritte richtig erkannte Dysfunktion wird auch behandelt. Schlussfolgerung: Erkennen und Behandeln sexueller Dysfunktionen sollten im Rahmen der Ausbildung stärker berücksichtigt werden. / Prevalence data on sexual dysfunctions indicate a high need for therapy and health care for sexual problems. One of the study’s aims was to investigate the extent of that need in patients of a psychotherapeutic university outpatient clinic. Besides, we examined to what extent sexual problems are recognised and treated by behaviour therapists in training. Patients and Methods: In a patient study, we tested 173 outpatients (aged 16-64 years, 71.7% female) who were seeking psychotherapy. By completing the German version of the Massachusetts General Hospital Sexual Functioning Questionnaire, participants rated their sexual interest, their ability to sexual arousal, to experience orgasm, to attain erection/lubrication and their general sexual satisfaction in the past month. In a therapist study, we examined whether 16 therapists in training were able to differentiate between patients with and without sexual dysfunction, whether they brought up the topic during therapy and whether they treated the sexual dysfunction. Results: Depending on the type of problem, one out of two to three women and one out of three to five men report sexual problems. Therapists recognise sexual problems in half of the patients, and bring up the issue of sexuality in every second patient. In fact, every third case of sexual dysfunction is treated. Conclusion: Behaviour therapy training should put a stronger emphasis on the topic of ‘sexual dysfunctions’. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

The aims of the present thesis were: * To investigate how women patients with borderline personality disorder (BPD) perceive their suffering, quality of life and encounter with psychiatric care (paper 11 and III). * To describe BPD patients' and psychiatric professionals' perceptions of receiving and giving dialectical behavioural therapy, DBT (paper I). * To investigate how starting treatment of BPD patients with DBT affected the psychiatric professionals' experience of occupational stress and professional burnout (paper IV) Due to the different types of research questions the thesis deal with, it uses a mix of qualitative and quantitative research methods. In two of the studies (11 and 111) the main methods were qualitative. Data from free format questionnaires, individual- as well as group interviews and biographical texts, were analysed with content analysis or a hermeneutic approach. In study Ill the methods were quantitative. A summated rating scale measuring healthrelated quality-of-life (HRQOL) was analysed with descriptive and inferential statistics. In study IV quantitative and qualitative methods were combined. Two burnout inventories were analysed with descriptive and inferential statistics, and data from free format questionnaires and group interviews were analysed with qualitative content analysis. The main findings were that BPD patients suffer to an extent that is often unendurable, leading to deliberate self-harm (DSH) and suicide attempts to relieve suffering or just try to get away from it all (paper 11). In study Ill the BPD patients showed significantly poorer quality-of-life (even physical) than normal population controls of comparable age. The suffering, suicide attempts, DSH and poor quality-of-life (paper 11 and 111) put the patients in a position of voluntarily or involuntarily getting involved with psychiatric care. Study II revealed a double role of the psychiatric care in relation to BPD patients. On one hand, psychiatric professionals can add to the suffering by not being understanding and being disrespectful, on the other hand they can be helpful and relieve suffering by being respectful, understanding and validating. There was a clear relationship between the patients' experience of validation and the experience of being helped. DBT seems (both from the patients' and psychiatric professionals' perspective) to be a treatment with a philosophy, content and structure being able to relieve BPD patients suffering and helping them to independence and a bearable life-situation (paper I). Study IV confirms previous findings that psychiatric professionals experience treatment of self-harming patients as profoundly stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients due to its high degree of structure and specific techniques. The DBT team-work and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some professionals felt also improved their handling of other work stressors not related to DBT. This finding also corresponds to BPD patients' perceptions of the mindfulness component in DBT, which they reported as particularly helpful (paper 1). It should be noted that the patient samples in the thesis may be considered as a "worse off" subgroup among BPD patients, as they usually entered special treatment programs after a period of escalating symptoms, which standard psychiatric services had had difficulties handling. The rather small number of participants and the lack of equivalent andlor concurrent control groups in the quantitative studies limit the generalization of the results.

Syftet med föreliggande studie var att vidareutveckla en behandlingsspecifik följsamhetsskala för paniksyndrom vid internetförmedlad kognitiv beteendeterapi (IKBT). Studiens frågeställningar var 1) uppnår skalan tillräcklig interbedömarreliabilitet, 2) finns det ett samband mellan skalan och det tidigare använda följsamhetsmåttet antalet genomförda moduler, och 3) finns det ett samband mellan skalan och behandlingsutfallet. Interbedömarreliabiliteten mellan två bedömare testades genom två omgångar samskattning. 80 deltagare som behandlades med IKBT för paniksyndrom vid enheten för internetpsykiatri i Stockholm skattades sedan enligt den behandlingsspecifika följsamhetsskalan. Även antalet moduler deltagarna genomförde registrerades. Resultaten visade att skalan sammantaget hade en god interbedömarreliabilitet. Vidare korrelerade följsamhetsskalan positivt med både antalet genomförda moduler och behandlingsutfallet. Slutsats: Skattningsskalan vidareutvecklad i föreliggande studie visade indikationer på att vara ett tillförlitligt och användbart instrument för att mäta följsamheten till IKBT vid paniksyndrom. / The purpose of this study was to further develop a treatment-specific rating scale for adherence to internet-based cognitive behavioural therapy (ICBT) for panic disorder. The research questions for this study were 1) does the rating scale show satisfying inter-rater reliability, 2) is there an association between the rating scale and the commonly used measurement of adherence, module completion, and 3) is there an association between the rating scale and treatment outcome. The inter-rater reliability between two raters was assessed twice. 80 participants treated with ICBT for panic disorder at Internetpsykiatrin (the unit for internet-based cognitive behavioural therapy in Stockholm) were then assessed using the treatment-specific rating scale for adherence. Module completion was also registered. Results show that the rating scale had an overall satisfying inter-rater reliability. Furthermore, the rating scale correlated positively with both module completion and treatment outcome. Conclusion: The rating scale further developed in the present study showed indications of being a reliable and useful instrument for measuring adherence to ICBT for panic disorder.

Etude longitudinale comparative de l’efficacité d’un programme cognitivo-comportemental de groupe pour l’autogestion de la fibromyalgie : 112 patients suivis en ambulatoire à l’hôpital, âgés entre 18 et 66 ans, répartis au hasard dans un bras traitement GTCC (8 séances, 2 heures par semaine) ou dans un bras témoin GTEM (1 séance, 2 heures d’information d’éducation thérapeutique) organisés en groupes de 5 à 9 patients. Tous ont répondu à des questionnaires avant l’intervention et ont été réévalués avec des tests cliniques 3, 6 et 12 mois après le traitement. Les résultats montrent : il n’y pas de différences significatives entre GTCC et GTEM. Pour GTCC nous constatons des changements significatifs : amélioration de la motivation au maintien des acquis, de la qualité de vie spécifique à la fibromyalgie, de l’état de santé général ; et diminution du coping dramatisation, de l’intensité de la douleur, de l’anxiété et de la dépressivité. La sévérité de la douleur, reste inchangée. La dépressivité et la douleur peuvent jouer un rôle prédictif du développement de facteurs cliniques. Un programme TCC pour l’autogestion de la fibromyalgie est efficace à court et long terme / A longitudinally comparative study assessed a group self-management CBT program efficacy for 112 fibromyalgia hospital outpatients, aged 18 to 66. They were andomized in treatment group GTCC (8 weekly 2 hours sessions) and reference group GTEM (one 2 hours therapeutic patient education session), both organized with 5 to 9 patients. All patients were submitted a socio-demographic data and clinical questionnaire before intervention and a clinical re-evaluation at 3, 6 and 12 months after treatment. No significant differences between GTCC and GTEM groups were found. GTCC results shows significant short and long-term improvement in motivation to maintain the new strategies, quality of life and health status; and in decreased catastrophizing coping strategies, pain intensity, anxiety and depression propensity. No change in pain severity was found. Depression and pain can predict the development of psychological and clinical factors. A fibromyalgia self-management CBT program is efficient at short and long term.