Adolescent and young Canadians are a group with the highest rates of symptoms of anxiety and depression. Such conditions, when unaddressed, negatively impact the development of a person, restricting their chances of attaining a fulfilling future and career. Even when deciding to reach out to access care, the process can be a challenging one with many barriers along the way. Online therapies in the form of online Cognitive Behavioural Therapies, have shown to be a promising format for some, but have faced some shortcomings with low uptake and variable results. Adding guidance and support to such therapies has been shown to help address these barriers. The objective of this research is to explore how support is currently provided for online cognitive behaviour therapies for anxiety and depression, targeting adolescents and young adults. To achieve this objective a scoping review methodology was utilized to identify relevant articles. The approach taken in a scoping review methodology allows for identification of a wide range of articles, which was necessary in this case because research isolating support features from other interventions is very limited. The scoping review identified fifty articles to be reviewed, and they were analyzed using a framework created for this review. The framework covered human, delivery, and design factors. Consultations with five key informants was also used to identify more findings related to the themes identified in the framework and to complement the findings from the articles in the scoping review. The resulting picture identified the field of support for online CBT for anxiety and depression in adolescents and young adults, covering a field with a great diversity ranging from virtual guides to face-to-face support from therapists. The features were organized into groups of ‘toolkits’ that can be considered by CBT developers for different situations and needs. / Thesis / Master of Science (MSc)

Objective 1: To examine the influence of maternal depression and/ or anxiety on infant, maternal and dyadic FFSF task performance Objective 2: To investigate the changes in infant and maternal FFSF task performance before and after Cognitive Behavioural Therapy (CBT) treatment of maternal depression / Background: Research suggests that postpartum depression (PPD) and postpartum anxiety (PPA) impact both mothers and their infants, leading to adverse behavioural outcomes across the lifespan. The face-to-face still-face (FFSF) task is a validated observational tool used to measure the quality of mother-infant interactions. This thesis aimed to investigate the differences in responses to the FFSF task between dyads consisting of mothers with PPD and/or PPA and healthy dyads. Another goal was to examine whether PPD treatment could improve mother and infant FFSF outcomes. Methods: A systematic search was performed in PubMed/MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science. Meta-analyses were conducted to examine the differences in infant, maternal and dyadic FFSF outcomes in mothers with PPD, PPA or comorbid PPD and PPA in comparison to healthy control dyads. Second, we examined whether group cognitive behavioural therapy (CBT) for PPD could help improve infant and maternal FFSF outcomes. A case-control design study was conducted with three different assessment points (i.e., pre-CBT treatment, immediately after CBT and three months post-CBT). Results: Meta-analyses suggested that the infants of mothers with PPD display lower levels of positive affect during the play and reunion phases compared to the infants of healthy non-depressed mothers. Also, mothers with PPD may engage less positively with their infants at the reunion phase, and mother-infant dyads affected by PPD show less positive interactive matching during the play phase compared to healthy control dyads. Finally, object/environment engagement was higher in infants of PPA mothers compared to healthy controls at still-face. Conclusion: The results suggest that mothers with PPD and/or PPD (and their infants) may exhibit different interaction patterns compared to healthy dyads. Also, it appears that the benefits of CBT for maternal PPD may extend to their infants through reductions in maladaptive infant withdrawn behaviours to normal, healthy levels. / Thesis / Master of Science (MSc) / Maternal postpartum depression (PPD) and postpartum anxiety (PPA) are the most common mental health complications of birth. Apart from unfavourable effects PPD and PPA have on mothers, it may also impact the mother-infant relationship, leading to adverse infant outcomes. Given the relatively high prevalence of maternal PPD, PPA, and comorbid PPD and PPA, this thesis aimed to examine the differences in how mothers suffering from PPD and/or PPA and their infants coordinate their behaviour, in comparison to healthy mothers and their infants using a validated observational task (face-to-face still-face [FFSF] task). Another goal of this thesis was to investigate whether the benefits of maternal treatment for PPD with cognitive behavioural therapy may extend to infants and improve mother, as well as infant behaviour. These investigations may provide new insights on how maternal PPD and/or PPA affects mother-infant interactions, and consequently, infant socio-emotional development.

Objectives: To assess the feasibility and effectiveness of an online 1-day cognitive behavioural therapy (CBT)-based workshop in the prevention of postpartum depression (PPD) Methods: In Study 1, data was analyzed from a cohort of 38 birthing parents in the form of a pre-test-post-test pilot study. The ability to develop a 1-day prevention intervention, with feasible study design, recruitment, and retainment strategies that was acceptable to participants was assessed and effect sizes were preliminarily measured in preparation to develop a future full-scale randomized control trial (RCT). In Study 2, a parallel-group RCT was utilized to examine a new group of 124 participants split into either the experimental or control group. Participants received the workshop plus treatment as usual (TAU; experimental group) or TAU alone (control), Major depressive disorder (MDD) diagnosis, levels of PPD symptoms, anxiety, social support, mother-infant relationship quality, and infant temperament was assessed at one, two, and three months postpartum. Results: In Study 1, a 1-day prevention intervention for PPD that was deemed acceptable to study participants was successfully developed. The online 1-day CBT-based workshops for preventing PPD were feasible in terms of study design based on participant recruitment speed and retention rate. In Study 2, trial recruitment was stopped after 25% of the expected sample size was recruited as fewer than 10% of participants in either group developed MDD at three months postpartum. Data were collected up to three months postpartum in those already enrolled. Among all enrolled participants (n=124), a trend toward larger reductions in EPDS scores was seen in the experimental group at two months postpartum (p=0.06). Participants with baseline Edinburgh Postnatal Depression Scale Score ≥7 in the experimental group showed larger, statistically significant reductions in PPD and anxiety at two months postpartum. Conclusion: The studies in this thesis suggest that the 1-day online CBT-based workshop could have potential as an intervention for preventing PPD in birthing parents considered higher-risk. Keywords: Postpartum depression, pregnancy, perinatal care, prevention and control, cognitive behavioural therapy, mental disorders / Thesis / Master of Science (MSc) / Postpartum depression is an ideal disorder for prevention due to its high prevalence, clear window for intervention (pregnancy), and easily identifiable risk factors. The objective of this thesis was to determine whether an online 1-day CBT-based workshop, was feasible for participants and whether it was effective in preventing PPD. In the first study the ability to design a 1-day intervention, as well as the feasibility of its study design, recruitment and retention strategies on participants were assessed. In the second study its effectiveness at preventing PPD was examined. We found that our 1-day workshop was feasible for participants and showed promise in preventing PPD in higher-risk samples. This research can provide guidance for future preventive interventions to improve outcomes for birthing parents at risk of developing PPD.

Introduction The prevalence of depressive symptoms in persons with heart failure is higher than in age- and gender-matched populations not suffering from heart failure. Heart failure in itself is associated with an unpredictable trajectory of symptoms, a poor prognosis, high mortality and morbidity, and low health-related quality of life (HrQoL). With the addition of depressive symptoms to heart failure the negative health effects increase further. Though the negative consequences of depressive symptoms in heart failure are well known, there is a knowledge gap about the course of depressive symptoms in heart failure and about how to effectively manage these symptoms. Pharmacological treatment with serotonin reuptake inhibitors has not been able to demonstrate efficacy in persons with heart failure. In a few studies, cognitive behavioural therapy (CBT) delivered face-to-face, has demonstrated effects on depressive symptoms in persons with heart failure. However, currently there are barriers in delivering face-to-face CBT as there is a lack of therapists with the required training. As a solution to this, the use of Internet-based CBT (ICBT) has been proposed. ICBT has been shown to be effective in treatment of mild and moderate depression but has not been evaluated in persons with heart failure. Aim The overall aim of this thesis was to describe depressive symptoms over time and to develop and evaluate an ICBT intervention to treat depressive symptoms in persons with heart failure. Design and Methods The studies in this thesis employ both quantitative (Studies I, II and III) and qualitative (Studies II and IV) research methods. The sample in Study I (n=611) were recruited in the Netherlands. The participants (n=7) in Study II were recruited via advertisements in Swedish newspapers. Studies III and IV used the same cohort of participants (Study III n=50, Study IV n=13). These participants were recruited via an invitation letter sent to all persons who had made contact with healthcare services in relation to heart failure during the previous year, at the clinics of cardiology or medicine in four hospitals in southeast Sweden. Study I had a quantitative longitudinal design. Data on depressive symptoms was collected at baseline (discharge from hospital) and after 18 months. Data on mortality and hospitalisation was collected at 18 and 36 months after discharge from hospital. Study II employed three differentBehind the Screen2patterns of design, as follows: I) The development and context adaptation of the ICBT program was based on research, literature and clinical experience and performed within a multi-professional team. II) The feasibility of the program from the perspective of limited efficacy and function was investigated with a quantitative pre-post design. III) Participants’ experience of the ICBT program was investigated with a qualitative content analysis. Data on depressive symptoms was collected pre and post intervention. The time used for support and feedback was logged during the intervention, and qualitative interviews were performed with the participants after the end of the intervention. Study III was designed as a randomised controlled trial. A nine-week ICBT program adapted to persons with heart failure and depressive symptoms was tested against an online moderated discussion forum. Data on depressive symptoms, HrQoL and cardiac anxiety was collected at baseline (before the intervention started) and after the end of the intervention (approximately 10 weeks after the start of the intervention). Study IV had a qualitative design to explore and describe participants’ experiences of ICBT. The participants were recruited from within the sample in Study III and all had experience of ICBT. Data collection occurred after the ICBT program ended and was carried out using qualitative interviews by telephone. Results The mean age of the samples used in this thesis varied between 62 and 69 years of age. Concerning the symptom severity of heart failure, most persons reported New York Heart Association (NYHA) class II (40-57%) followed by NYHA class III (36-41%). Ischaemic heart disease was the most common comorbidity (36-43%). The vast majority had pharmacological treatment for their heart failure. Six percent of the persons in Study I used pharmacological antidepressants. In Studies II and III, the corresponding numbers were 43% and 18% respectively. Among persons hospitalised due to heart failure symptoms, 38% reported depressive symptoms. After 18 months, 26% reported depressive symptoms. Four different courses of depressive symptoms were identified: 1) Non-depressed 2) Remitted depressive symptoms. 3) Ongoing depressive symptoms. 4) New depressive symptoms. The highest risk for readmission to hospital and mortality was found among persons in the groups with ongoing and new depressive symptoms. A nine-week ICBT program consisting of seven modules including homework assignments on depressive symptoms for persons with heart failure was developed and tested. The RCT study (Study III) showed no significant difference in depressive symptoms between ICBT and a moderated discussion forum. Within-group analysis of depressive symptoms demonstrated a significant decrease of depressive symptoms in the ICBT group but not in the discussion forum group. The participants’ experience of ICBT was described in one theme: ICBT- an effective, but also challenging tool for self-management of health problems. This theme was constructed based on six categories: Something other than usual healthcare; Relevance and recognition; Flexible, understandable and safe; Technical problems; Improvements by live contact; Managing my life better. Conclusion After discharge from hospital, depressive symptoms decrease spontaneously among a large proportion of persons with heart failure, though depressive symptoms are still common in persons with heart failure that are community dwelling. Depressive symptoms in persons with heart failure are associated with increased risk of death and hospitalisation. The highest risks are found among persons with long-term ongoing depressive symptoms and those developing depressive symptoms while not hospitalised. ICBT for depressive symptoms in heart failure is feasible. An intervention with a nine-week guided self-help program with emphasis on behavioural activation and problem-solving skills appears to contribute to a decrease in depressive symptoms and improvement of HrQoL. When ICBT is delivered to persons with heart failure and depressive symptoms the participants requests that the ICBT is contextually adapted to health problems related to both heart failure and depressive symptoms. ICBT is experienced as a useful tool for self-care and something other than usual healthcare. ICBT also requires active participation by the persons receiving the intervention, something that was sometimes experienced as challenging.

Det råder frågetecken om hur följsamhet till behandlingens metoder inom internetbaserad kognitiv beteendeterapi (IKBT) för depression påverkar symtomreduktion. Syfte: undersöka sambandet mellan följsamhet till behandlingsmetoder inom IKBT och symtomreduktion, för depressionspatienter. Frågeställning: föreligger samband mellan följsamhet till behandlingens metoder och symtomreduktion. Metod: deltagarna var 90 patienter, vilka behandlats för depression vid Internetpsykiatrin i Stockholm. Antal moduler deltagarna genomfört registrerades, och mängd och kvalité utförande hemuppgifter skattades enligt en behandlingsspecifik följsamhetsskala. Symtomreduktion mättes genom förändring i depressionsnivå, från förmätning till eftermätning. Resultat: samband påvisades mellan antal genomförda moduler och symtomreduktion, men inte mellan mängd och kvalité utförande hemuppgifter och symtomreduktion. Mängd och kvalité tillförde ingen ytterligare förklaring av variansen för symtomreduktion än antal genomförda moduler. Slutsats: det förefaller viktigare att patienter kommer framåt i behandlingen, än hur behandlingsmetoderna utförs. / There are questions about how adherence to treatment methods in Internet-based cognitive behavioral therapy (ICBT) for depression affects symptom reduction. Purpose: explore the relationship between adherence to treatment methods within internet-based cognitive behavioral therapy (ICBT) and symptom reduction, for depressed patients. Research question: is there a relationship between adherence to treatment methods and symptom reduction. Method: the participants were 90 patients treated for depression at the Internetpsykiatri in Stockholm. The number of modules completed was registered, the amount and quality of homework was estimated by a treatment-specific adherence scale. Symptom reduction was measured by changes in level of depression, from pre-measurement to post-measurement. Results: correlation was demonstrated between number of completed modules and symptom reduction, but not between amount and quality of homework and symptom reduction. Amount and quality did not add more explanation of the variance in symptom reduction than the number of completed modules. Conclusions: it is more important that patients advance in the treatment, than how the treatment methods are performed.

As the literature on work–family conflict grows and absenteeism increasingly comes into the spotlight, one cannot help but ask the question: “What is an acceptable absenteeism rate and how can an organisation control and manage absenteeism?” With current absenteeism rates as high as 12% and with an estimated R12 million lost per annum because of absenteeism, the idea of an on-site employer-sponsored childcare facility seems viable. The purpose of this study is to examine the relationship between absenteeism and on-site employer- sponsored childcare. The following dimensions of absenteeism will be examined over a period of a year: absence frequency, absence intensity, attitudinal absence and medical absence. The results of two companies, one with a facility and one without, will then be compared in order to establish the relationship between absenteeism and an on-site facility. To date, evidence remains mixed and the ongoing challenge of establishing real return on equity remains a major barrier to the support of on-site employer-sponsored childcare. / Industrial & Organisational Psychology / M. A. (Industrial and Organisational Psychology)

Tools for measuring competence in delivering Cognitive Behavioural Therapy (CBT) provide a means of assessing the training of new CBT therapists and ensuring the quality of treatment provision within routine practice, provide a framework for delivering formative feedback, promote ongoing self-reflection, and are essential to establishing treatment integrity in research trials. As such, identifying an optimal strategy for assessing the competence with which CBT is delivered is crucial to the continued progression of the field. However, research in this area has been somewhat limited to date. Thus, there are at present no evidence-based best practice guidelines outlining the way CBT competence should be assessed. Furthermore, many of the assessment measures currently available have been widely criticised, indicating a need for improved tools for assessing CBT competence. To begin addressing this issue, the first two chapters of this thesis focus on reviewing and evaluating current assessment methods. Chapter one provides a systematic review of current methods of assessing CBT competence and chapter two outlines a qualitative exploration of experts’ understandings and experiences of assessing CBT competence. Findings from these studies provide tentative recommendations for practitioners and researchers assessing CBT competence. These initial studies also highlight ways in which the assessment of CBT competence could be improved and therefore provide a platform for guiding subsequent thesis chapters which focus on further developing existing assessment measures. Specifically, chapters three to six focus on the development and evaluation of a novel CBT competence rating scale: the Assessment of Core CBT Skills (ACCS). The ACCS builds upon currently available scales (especially the Cognitive Therapy Scale- Revised: CTS-R) to provide an assessment framework for assessors to deliver formative and summative feedback regarding therapists’ performance within observed CBT treatment sessions and for therapists to rate and reflect on their own performance. Development of the ACCS involved three key stages: 1- theory-driven scale development (chapter three), 2- an ‘expert’ review of the content validity, face validity, and usability of the scale (chapter four), and 3- an evaluation of the scale involving a pilot study examining its psychometric properties (chapter five) and a focus group examining its usability and utility (chapter six). Results from these studies indicate that the ACCS is a useful learning tool, is easy to use, has good psychometric properties, and offers an acceptable alternative to the CTS-R. Finally, chapter seven examines whether assessors require training in how to use the ACCS, concluding that simply reading the ACCS manual may be sufficient to achieve acceptable levels of reliability and usability. The results from the thesis are then drawn together in the final concluding comments in chapter eight, which discusses the findings within the broader context of the assessment of CBT competence.

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.