Family-focused intervention programme to foster adolescent mental health and well-being: protocol for a multicountry cluster randomised factorial trial (FLOURISH Phase 2) Antonio Piolanti, Janina Mueller, Franziska Waller, Nina Heinrichs, Judit Simon, et al. BMJ Open, 2025 Introduction Adolescent mental health problems represent a significant global health issue, particularly in low- and middle-income countries, such as the Republic of North Macedonia and the Republic of Moldova. Effective and scalable interventions are urgently needed to address these challenges. Methods and analysis This protocol outlines a multicountry cluster randomised factorial trial, implemented according to the multiphase optimisation strategy (Phase 2), which evaluates the effectiveness and costs of three add-on components for the Parenting for Lifelong Health for Parents and Teens programme: adolescent mental health tools based on UNICEFs Helping Adolescents Thrive comics, adolescent peer support based on UNICEFs ‘I Support My Friends’ intervention and engagement booster designed to enhance attendance and programme completion through incentives. The study will recruit 720 families and involve 64 clusters in North Macedonia and Moldova. Primary outcomes will include adolescent internalising problems and social support, family functioning and attendance during the programme. Secondary outcomes will assess broader aspects of mental health among caregivers and adolescents, as well as implementation and cost outcomes. Data will be collected at baseline and postintervention, approximately, 8 weeks later. Statistical analyses will include regression models to assess the main and interaction effects of the intervention components and cost analyses. Ethics and dissemination The study received ethical approval from the University of Klagenfurt in Austria (approval number: 2023–013), the Medical Faculty at St. Cyril and Methodius University in North Macedonia (approval number: 03-2144/4) and the National Committee of Ethical Expertise for Clinical Trials in Moldova (approval number: 1476). The results will be disseminated through peer-reviewed journals, conferences, webinars in multiple languages, regional forums, stakeholder meetings with policymakers and practitioners, public communication through media engagement and open access platforms, including data sharing and early release of findings. Trial registration details Trial registration: NCT06562244 ; Project page: https://www.flourish-study.org/about.html
Adverse event assessment in a parenting programme: experiences from a multisite randomised controlled trial Inga Frantz, Heather M. Foran, Jamie M. Lachman, Frances Gardner, Robert J. McMahon, et al. Trials, 2024 Background Clinicians and researchers should consider the expected benefits and potential harms of an intervention. Parenting programmes are a widely used evidence-based intervention for child behaviour problems. However, few data are available on potential negative effects. The aims of this paper were to increase systematic knowledge of adverse event (AE) assessment in parenting programmes and to provide an AE assessment tool. Methods As part of the RISE project (prevention of child mental health problems in South-eastern Europe—adapt, optimise, test and extend parenting for lifelong health), we developed and tested an AE assessment procedure in three sequential studies for parents of children with child behaviour problems aged 2 to 9 years in North Macedonia, Republic of Moldova, and Romania. This paper reports on the development of the assessment tool in phase 1 (N = 140), phase 2 (N = 835), and the final experiences with using the optimised procedures in phase 3 (multisite randomised controlled trial, N = 823) in which AEs were assessed before, three times during intervention delivery, and at 1 year follow-up. At each time point, the participants completed a 12-item AE checklist. If moderate-to-severe problems of parent or child were reported, a structured follow-up interview was conducted. Results The response rate on the AE assessment tool increased from 6% (phase 1) to 100% (phase 3) indicating improvement in collecting these data based on the experiences of each phase. Results of the RCT (phase 3) showed generally low (S)AE frequencies with the finally optimised procedure: During the intervention, no serious adverse events (SAE) were registered; at least one AE was reported by 10% (after the first session), 7% (after the third session), and 4% (after the last fifth session) of participants. None of the identified (S)AEs was causally related to the study or intervention. Cost–benefit considerations are needed to determine the best way to ensure participant safety in parenting programmes. Conclusion The applied active AE assessment procedure provides a comprehensive AE assessment tool that can be used by others—with adaptations for the specific context, if needed. Based on our experiences, we outline recommendations for future studies. Trial registration ClinicalTrials.gov, registration number phase 1: NCT03552250; phase 2: NCT03865485, phase 3: NCT04721730. Registered on 13 January 2021.
Factor structure of the Depression, Anxiety and Stress Scale among caregivers in Southeastern Europe Hugh Murphy, Katharina Prandstetter, Catherine L. Ward, Judy Hutchings, Ivo Kunovski, et al. Family Relations, 2024 ObjectiveThis study aimed to evaluate the factor structure of the Depression Anxiety and Stress Scale (DASS‐21) among caregivers of young children in Southeastern Europe.BackgroundThe DASS‐21 is a widely used measure in prevention and intervention research with families. Studies regarding the scale's psychometric properties among caregivers, particularly from non‐Western countries, are limited and additional research is required.MethodThe DASS‐21 was administered to N = 835 primary caregivers from North Macedonia, the Republic of Moldova, and Romania. Competing models were tested with confirmatory factor analysis (CFA). Measurement invariance was assessed using multigroup CFA (MGCFA). Bifactor dimensionality and reliability indices were used to evaluate the validity of the composite and subscale scores.ResultsA tripartite bifactor model with two specific factors (depression and anxiety) and one general factor (negative affectivity) represented the data well. This model showed cross‐country configural and partial metric invariance. Dimensionality and reliability indices supported a unidimensional interpretation of the measure, with the general negative affectivity factor accounting for a substantial share of the variance (82%) compared to the specific factors of depression (10%) and anxiety (8%).ConclusionThe tripartite model best represented the data. Configural and partial metric invariance were verified for this model. Dimensionality and reliability indices, however, indicate that the DASS‐21 functions best as a general measure of negative affectivity.ImplicationsFuture intervention studies involving caregivers from Southeastern Europe should consider using the DASS‐21 as an overall measure of negative affectivity and utilize the composite score instead of the subscale scores.
Six-country psychometric comparison of women responses to the Depression Anxiety Stress Scale (DASS) and the Child and Adolescent Behaviour Inventory (CABI) across cultures and … FAC Alfaro, J Lachman, CL Ward, Q Han, R Jocson, I Kunovski, ... Journal of Affective Disorders 387, 119524 , 2025 2025.0
Does it get worse before it gets better? Outcomes from a parent-adolescen parenting program in North Macedonia I Kunovski, M Raleva, N Pachoska, M Bilinska, R Krsteska, ... 2025.0
Family-focused intervention programme to foster adolescent mental health and well-being: protocol for a multicountry cluster randomised factorial trial (FLOURISH Phase 2) A Piolanti, J Mueller, F Waller, N Heinrichs, J Simon, Y Shenderovich, ... BMJ open 15 (2), e094085 , 2025 2025.0 Citations: 1
Provisional A Piolanti, J Mueller, F Waller, N Heinrichs, J Simon, Y Shenderovich, ... 2024.0
Adverse event assessment in a parenting programme: experiences from a multisite randomised controlled trial I Frantz, HM Foran, JM Lachman, F Gardner, RJ McMahon, T Ogden, ... Trials 25 (1), 547 , 2024 2024.0 Citations: 4
The bidirectional temporal relationship between parenting stress and child maltreatment: A cross-lagged study based on intervention and cohort data Q Han, R Jocson, I Kunovski, M Raleva, R Juhari, K Okop, A Oppler, ... Journal of affective disorders 354, 302-308 , 2024 2024.0 Citations: 20
Factor structure of the Depression, Anxiety and Stress Scale among caregivers in Southeastern Europe H Murphy, K Prandstetter, CL Ward, J Hutchings, I Kunovski, D Tăut, ... Family Relations 73 (2), 905-920 , 2024 2024.0 Citations: 17
Effectiveness of an online parenting program for childhood anxiety in North Macedonia I Kunovski, M Raleva Archives of Public Health 15 (2) , 2023 2023.0 Citations: 1
COPING STYLES AND MENTAL HEALTH IN HEALTHCARE WORKERS DURING THE COVID-19 PANDEMIC I Kunovski, S Bajraktarov, V Isjanovski Academic Medical Journal 3 (3), 30-40 , 2023 2023.0
Depression and anxiety in adolescents and their caregivers: A cross-sectional study from North Macedonia S Bajraktarov, I Kunovski, M Raleva, F Bolinski, R Isjanovska, G Kalpak, ... Prilozi 44 (1), 47-56 , 2023 2023.0 Citations: 7
Symptoms of depression and anxiety in adolescents and their caregivers: A cross-sectional study from North Macedonia I Kunovski, F Bolinski, M Raleva, R Isjanovska, G Kalpak, A Novotni, ... European Psychiatry 66 (Suppl 1), S201-S201 , 2023 2023.0
Preventing Child Maltreatment and Promoting Family Wellbeing through Online Parent Support Groups in Six Countries Q Han, J Lachman, R Juhari, I Ferdinandi, M Raleva, R Jocson, ... Society for Prevention Research 30th Annual Meeting , 2022 2022.0
Online Implementation of a Parenting Intervention for Parents of Children with Behavioural Problems: Implementation Data from a Multi-Site RCT in Southeastern Europe (RISE) D Taut, J Hutchings, A Baban, C Ward, N Heinrichs, H Foran, F Gardner, ... Society for Prevention Research 30th Annual Meeting , 2022 2022.0
Effects of childhood abuse and neglect on suicidal behavior in an adolescent clinical population I Kunovski, G Nikolova, A Filipovska, L Trpcevska, M Raleva European psychiatry 56, S65-S66 , 2019 2019.0 Citations: 12
Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder in international humanitarian aid workers: Study protocol I Kunovski, T Donker, E Driessen, P Cuijpers, G Andersson, M Sijbrandij Internet interventions 10, 23-28 , 2017 2017.0 Citations: 2
Effectiveness of internet‐delivered cognitive behavioral therapy for posttraumatic stress disorder: A systematic review and meta‐analysis M Sijbrandij, I Kunovski, P Cuijpers Depression and anxiety 33 (9), 783-791 , 2016 2016.0 Citations: 265
Parental Support through Promoting the Concept of Positive Parenting N Petrovska, NS Trajkovska, I Kunovski, AK Ristovska, S Georgievska, ... CONFERENCE PROCEEDINGS of the 1st International Conference–Challenges of … , 0
Family Functioning in low-resource settings: Associations between caregivers’ psychological distress and well-being while considering contextual factors J Müller, E Jansen, B Radlingmaier, J Hutchings, CL Ward, N Heinrichs, ...
MOST CITED SCHOLAR PUBLICATIONS
Effectiveness of internet‐delivered cognitive behavioral therapy for posttraumatic stress disorder: A systematic review and meta‐analysis M Sijbrandij, I Kunovski, P Cuijpers Depression and anxiety 33 (9), 783-791 , 2016 2016.0 Citations: 265
The bidirectional temporal relationship between parenting stress and child maltreatment: A cross-lagged study based on intervention and cohort data Q Han, R Jocson, I Kunovski, M Raleva, R Juhari, K Okop, A Oppler, ... Journal of affective disorders 354, 302-308 , 2024 2024.0 Citations: 20
Factor structure of the Depression, Anxiety and Stress Scale among caregivers in Southeastern Europe H Murphy, K Prandstetter, CL Ward, J Hutchings, I Kunovski, D Tăut, ... Family Relations 73 (2), 905-920 , 2024 2024.0 Citations: 17
Effects of childhood abuse and neglect on suicidal behavior in an adolescent clinical population I Kunovski, G Nikolova, A Filipovska, L Trpcevska, M Raleva European psychiatry 56, S65-S66 , 2019 2019.0 Citations: 12
Depression and anxiety in adolescents and their caregivers: A cross-sectional study from North Macedonia S Bajraktarov, I Kunovski, M Raleva, F Bolinski, R Isjanovska, G Kalpak, ... Prilozi 44 (1), 47-56 , 2023 2023.0 Citations: 7
Adverse event assessment in a parenting programme: experiences from a multisite randomised controlled trial I Frantz, HM Foran, JM Lachman, F Gardner, RJ McMahon, T Ogden, ... Trials 25 (1), 547 , 2024 2024.0 Citations: 4
Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder in international humanitarian aid workers: Study protocol I Kunovski, T Donker, E Driessen, P Cuijpers, G Andersson, M Sijbrandij Internet interventions 10, 23-28 , 2017 2017.0 Citations: 2
Family-focused intervention programme to foster adolescent mental health and well-being: protocol for a multicountry cluster randomised factorial trial (FLOURISH Phase 2) A Piolanti, J Mueller, F Waller, N Heinrichs, J Simon, Y Shenderovich, ... BMJ open 15 (2), e094085 , 2025 2025.0 Citations: 1
Effectiveness of an online parenting program for childhood anxiety in North Macedonia I Kunovski, M Raleva Archives of Public Health 15 (2) , 2023 2023.0 Citations: 1
Six-country psychometric comparison of women responses to the Depression Anxiety Stress Scale (DASS) and the Child and Adolescent Behaviour Inventory (CABI) across cultures and … FAC Alfaro, J Lachman, CL Ward, Q Han, R Jocson, I Kunovski, ... Journal of Affective Disorders 387, 119524 , 2025 2025.0
Does it get worse before it gets better? Outcomes from a parent-adolescen parenting program in North Macedonia I Kunovski, M Raleva, N Pachoska, M Bilinska, R Krsteska, ... 2025.0
Provisional A Piolanti, J Mueller, F Waller, N Heinrichs, J Simon, Y Shenderovich, ... 2024.0
COPING STYLES AND MENTAL HEALTH IN HEALTHCARE WORKERS DURING THE COVID-19 PANDEMIC I Kunovski, S Bajraktarov, V Isjanovski Academic Medical Journal 3 (3), 30-40 , 2023 2023.0
Symptoms of depression and anxiety in adolescents and their caregivers: A cross-sectional study from North Macedonia I Kunovski, F Bolinski, M Raleva, R Isjanovska, G Kalpak, A Novotni, ... European Psychiatry 66 (Suppl 1), S201-S201 , 2023 2023.0
Preventing Child Maltreatment and Promoting Family Wellbeing through Online Parent Support Groups in Six Countries Q Han, J Lachman, R Juhari, I Ferdinandi, M Raleva, R Jocson, ... Society for Prevention Research 30th Annual Meeting , 2022 2022.0
Online Implementation of a Parenting Intervention for Parents of Children with Behavioural Problems: Implementation Data from a Multi-Site RCT in Southeastern Europe (RISE) D Taut, J Hutchings, A Baban, C Ward, N Heinrichs, H Foran, F Gardner, ... Society for Prevention Research 30th Annual Meeting , 2022 2022.0
Parental Support through Promoting the Concept of Positive Parenting N Petrovska, NS Trajkovska, I Kunovski, AK Ristovska, S Georgievska, ... CONFERENCE PROCEEDINGS of the 1st International Conference–Challenges of … , 0
Family Functioning in low-resource settings: Associations between caregivers’ psychological distress and well-being while considering contextual factors J Müller, E Jansen, B Radlingmaier, J Hutchings, CL Ward, N Heinrichs, ...