child and adolescent development research paper

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child and adolescent development research paper

Research priorities for child and adolescent physical activity and sedentary behaviours: an international perspective using a twin-panel Delphi procedure

International Journal of Behavioral Nutrition and Physical Activity volume 10 , Article number: 112 ( 2013 ) Cite this article

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The quantity and quality of studies in child and adolescent physical activity and sedentary behaviour have rapidly increased, but research directions are often pursued in a reactive and uncoordinated manner.

To arrive at an international consensus on research priorities in the area of child and adolescent physical activity and sedentary behaviour.

Two independent panels, each consisting of 12 experts, undertook three rounds of a Delphi methodology. The Delphi methodology required experts to anonymously answer questions put forward by the researchers with feedback provided between each round.

The primary outcome of the study was a ranked set of 29 research priorities that aimed to be applicable for the next 10 years. The top three ranked priorities were: developing effective and sustainable interventions to increase children’s physical activity long-term; policy and/or environmental change and their influence on children’s physical activity and sedentary behaviour; and prospective, longitudinal studies of the independent effects of physical activity and sedentary behaviour on health.

Conclusions

These research priorities can help to guide decisions on future research directions.

Recent research has shown that both physical activity and sedentary behaviour are associated with a wide range of current and future health outcomes [ 1 – 3 ]. In fact, physical activity and sedentary behaviour are two independent and not mutually exclusive behaviours with different effects on health outcomes [ 4 ]. In the short term, physical activity has been shown to be moderately and positively associated with bone health, aerobic fitness, blood lipid levels, self-esteem, mental activity and fundamental movement skills in children and adolescents [ 1 – 3 , 5 ]. In the long term, both physical activity and sedentary behaviour have been identified as major, independent, modifiable risk factors for mortality and morbidity from many chronic, non-communicable and potentially preventable diseases [ 6 – 9 ]. New evidence also suggests that the relation between sedentary behaviour and all-cause end cardiovascular disease mortality is independent of physical activity levels [ 7 ].

Chronic diseases place a large economic burden on health services and impose significant costs on society (e.g. premature death, underappreciated economic effects and greater reliance on treatment) [ 8 ]. Although the ill effects of chronic disease largely manifest in adulthood, it is increasingly understood that the development typically begins in childhood or adolescence [ 9 ]. Therefore, physical activity levels and sedentary behaviour performed in the early years could potentially influence the development of disease later on in life.

At present, a large quantity of research is being conducted into the physical activity and sedentary behaviour of children, yet the research community remains challenged to provide a solid evidence base [ 10 ]. This is in part due to a lack of international research collaboration and a high degree of study repetition. The aim of this study therefore was to arrive at a set of international research priorities for physical activity and sedentary behaviour to guide more meaningful and focussed research. Specifically, this study aimed to answer the following research question: “What are the most important international research issues for the next 10 years in child and adolescent physical activity and sedentary behaviour?” Agreement on research priorities may help to inform evidence-based policy, guide funding allocation, and direct research options for postgraduate students [ 11 , 12 ].

Existing literature

To identify existing evidence in this area, a systematic review of the English and non-English literature was performed using the following search terms: physical activit* OR motor activity (MeSH) OR sedentary behavio* AND child* OR adolescen* OR youth* AND research priorit* OR research agenda* OR research issue*. The databases PsychINFO (1887–), SPORTDiscus (1949–), Cochrane (1992–), CINAHL (1937–), ERIC (1966–) and PubMed (1950–) were searched in May 2012. Additional studies were also identified by contacting experts, Google searching and identifying potential studies in the reference lists of identified studies. Only four previously published papers that arrived at research priorities in child physical activity and/or sedentary behaviour were identified [ 11 , 13 – 15 ]. A working paper by Bull et al. [ 11 ] identified research priorities in physical activity with a focus on low to middle income countries. Evenson and Mota [ 13 ] highlighted research on the determinants and outcomes of physical activity and made recommendations for future study designs. Mountjoy et al. [ 15 ] identified existing gaps in physical activity research for children, with a focus on the need for greater collaboration between sport and existing programmes. The final study by Fulton et al. [ 14 ] had two aims. Firstly, the study aimed to review the current knowledge of existing methods for assessing physical activity and sedentary behaviour. Secondly, on the basis of this, the study aimed to set research priorities on the use of reliable and valid measurement tools to assess physical activity and sedentary behaviour in children aged 2–5 years.

While these studies were valuable contributions, they also had many limitations, including unsystematic participant selection, unstructured data collection procedures, and limited reporting on the process followed to arrive at the research priorities. Furthermore, the participants involved in the decision-making processes did not always represent the broader community of researchers, either from a geographical or institutional point of view. In addition, the anonymity of participants was not maintained during the consensus process. These limitations warranted a further study with an aim to arrive at a set of research priorities by employing a structured and rigorous methodology and improving reporting quality.

Methodology

Ethical approval for all aspects of the methodology was granted by the University of South Australia Human Research Ethics Committee in September 2011.

This study employed a Delphi procedure. This procedure is appropriate for research questions which cannot be answered with complete certainty, but rather by the subjective opinion of a collective group of informed experts [ 16 ]. It allowed systematic refinement of the experts’ opinions over the course of several rounds while minimising confounding factors present in other group response methods [ 17 – 20 ].

The experts who participated in the Delphi procedure were identified by a 3–step procedure. Firstly, the lead study investigators independently recommended known researchers for the study. Secondly, a lengthy and extensive search was carried out to identify potential researchers from every world region and sub-region. Identifying potential experts from these regions involved searching for staff of relevant international bodies, government departments, non-government organisations, professional organisations and educational institutions. Thirdly, following email communication with the experts who have previously been identified, new experts were referred to the study investigators.

Once participants had been identified, it was important to determine their eligibility for inclusion in the study. Thus they were assessed using pre-determined inclusion and exclusion criteria. To be eligible, a researcher had to be an author of at least one peer-reviewed scientific publication on the physical activity or sedentary behaviour of children or adolescents, and must hold (at the time of selection) a senior position in their organisation. In addition, the experts were deliberately chosen to give geographical coverage of every world region and sub-region. Relevant information was gathered from staff homepages, Scopus author searches, the Journal and Author Name Estimator ( http://www.biosemantics.org/jane/ ) and other relevant Internet searches to ascertain whether a researcher met these criteria.

Forty-six eligible experts were invited to participate, with each sent information and consent forms via email. As a whole, these participants were representative of every region and sub-region. Of those invited, 20 did not respond to the invitation, two declined to participate, and 24 returned signed consent forms. An outline of this process is illustrated in Figure 1 .

Purposive sampling process undertaken.

The 24 participating experts (17 male and 7 female) were randomly allocated to either Panel A or Panel B and assigned identification code names accordingly. Furthermore the following major institution types were represented by the selected experts; educational institutions, government organisations, non-government organisations, professional organisations and community organisations.

The Delphi procedure used three rounds [ 21 ], each consisting of data collection, data analysis and controlled feedback. The survey was administered entirely online using a Survey Gizmo questionnaire. A novel feature of this study was the use of two parallel panels of experts. The existence of an alternate panel was only made known to the participants in Round 3, when each panel was asked to rank the priorities of the other panel. This allowed quantitative comparisons to be made between each panel’s rankings of each research issue and cross-validated the rankings of research priorities developed by each panel.

To commence each round, experts were sent an email containing a direct link to the online questionnaire. Briefly, Round 1 required each expert to answer the question “What are the five most important research issues for the next 10 years in the area of child and adolescent physical activity and sedentary behaviour?” Each expert put forward five research issues which they believed were priorities in the area. They also provided a brief description of each issue and reasons why they believed the issue to be a priority. The three study investigators reviewed all issues that were provided by each panel, with common issues combined into a single issue. The experts were then fed back their panel’s list of research issues and asked to ensure that the five research issues they provided were accurately represented.

Round 2 then asked experts to “review the research issues put forward in Round 1 and rate how important they believe each issue is for global research in child and adolescent physical activity and sedentary behaviour”. Experts rated each research issue independently using a 5-point Likert scale (5 = very important, 4 = important, 3 = moderately important, 2 = of little importance and 1 = unimportant). The three study investigators then short-listed each panel’s research issues to 20 according to those with highest mean Likert scale ratings. Following this, the top 20 research issues from each panel were fed back to the experts of the relevant panels.

In Round 3, experts were first asked to “rank their panel’s top 20 research issues in order of perceived international importance in child and adolescent physical activity and sedentary behaviour over the next 10 years”. The experts were then similarly asked to rank the alternate panel’s top 20 research priorities. The data analysis procedure was as follows. Firstly, the overall sum of each panel’s rankings was calculated for Panel A and Panel B’s top 20 research issues. Secondly, the two lists of research issues were combined with common issues provided by both panels merged. This resulted in 29 unique issues. Thirdly, the experts’ individual rankings for each research issue were summed. This allowed the issues to be ranked according to the sum of Panel A and Panel B’s overall rankings for each issue. Intra-panel agreement was quantified using Spearman’s rho by creating a matrix to compare individuals’ rankings to one another within the same panel. Inter-panel agreement was also quantified using Spearman’s rho to compare the overall sum and rank for each issue between panels.

Expert demographics

All 24 experts completed the three Delphi rounds. Data was collected on the 24 experts’ geographical distributions, institutional affiliations and years worked in the study area.

As a group, the 24 experts represented every geographical region and 12 sub-regions. This geographical distribution is illustrated in Figure 2 .

Geographical distributions of participating experts. The numbers indicate the number of participating experts from that region.

In terms of institutional affiliation, twenty-three experts acknowledged they were affiliated with an educational institution, eleven were affiliated with a professional organisation, six with an international organisation, six with a non-government organisation and four with a government organisation. It was noted that due to the nature of their work, experts were often affiliated with more than one institution type.

In regards to years worked in the study area, twelve experts had worked in for greater than 16 years, five had worked for 11 to 15 years, four had worked for 6 to10 years and three had worked for less than five years.

Results from Delphi rounds

In Round 1, each expert put forward five research issues. Collectively this provided a total of 120 issues across all 24 experts, with 60 for each panel. Following qualitative reduction of overlapping issues, 26 issues from Panel A and 34 issues from Panel B, were carried forward to Round 2. On reviewing the amended list, all exerts agreed that the issues they had raised were adequately represented.

From Round 2, the mean Likert-scale ratings were used to determine the top 20 issues for each panel. For Panel A, the mean Likert-scale ratings of the top 20 issues ranged from 3.5 to 5.0, with 18 of 20 issues having a median rating of >4.0 (“important”). For Panel B, the mean Likert-scale ratings of the top 20 issues ranged from 4.0 to 4.8, with all 20 research issues having a median rating of >4.0.

In Round 3, the 20 issues from Panel A and 20 issues from Panel B were qualitatively analysed to form one list. Eleven of each panel’s top 20 research issues were common to both panels and were therefore combined, with the remaining 18 issues (nine from each panel) unique. The resultant was a set of 29 unique research issues that were then ranked in order of importance by summing Panel A and Panel B’s rankings for each issue Table 1 .

There was only weak intra-panel agreement. The mean inter-individual rho ( ± 95% CI) was 0.20 ±0.05 for Panel A and 0.13 ±0.04 for Panel B. The average standard deviation of the rankings for individual issues was 5.1 (Panel A) and 5.3 (Panel B). When Panel B ranked Panel A’s issues, the correlation was very strong ( rho ± 95% CI: 0.79 ±0.17), and when Panel A ranked Panel B’s issues, the correlation was strong ( rho ± 95% CI: 0.52 ±0.31). Figures 3 and 4 clearly illustrate the correlations for each research issue.

Agreement between Panel A’s rankings and Panel B’s rankings of Panel A’s identified issues. The line shown is the identity line.

Agreement between Panel B’s rankings and Panel A’s rankings of Panel B’s identified issues. The line shown is the identity line.

Study outcomes

The primary outcome of this study was the development of 29 international research priorities in child and adolescent physical activity and sedentary behaviour. In order for the research priorities to be useful, it is important that they be neither too general nor too specific. The research priorities in this study appear broad enough to enable them to be transferable to researchers’ specific regions and contexts.

The final set of research priorities address a broad range of areas from epidemiology, determinants and correlates, through to intervention effectiveness and translational research. Of the 29 identified research priorities, ten related directly to translational research centred on intervention design and effectiveness. These focussed on specific behaviours (active transport, screen time, sport, physical education), settings (schools, communities, whole of population), or vehicles (mass advertising, policy). Translational research, centred on intervention design and effectiveness, can potentially guide governments and stakeholders to fund interventions that are the most effective, sustainable and transferable for changing behaviours [ 7 ]. This is important because to date, the research community has not been very successful at developing interventions for children and adolescents that bring about long-term and sustained change in health behaviours [ 10 ]. In addition, little attention has been given to the importance of the intervention setting and establishing what works in what situation and with whom [ 22 ].

Nine of the research priorities had a focus on capturing and quantifying the health benefits of engaging in physical activity and limiting sedentary behaviour, These research priorities were concerned with the impact of physical activity and sedentary behaviour on obesity, cognition, and general health and well being, and on describing behavioural patterns (across the day or the life-course or in specific populations such as pre-school children). Epidemiological research was considered important to address the cause, distribution and patterns of childhood physical activity and sedentary behaviour on current and future health [ 2 , 6 , 9 , 23 ].

Six research issues related to determinants and correlates research such as psychosocial and cultural/parental factors, the impact of technology, and the importance of enjoyment and lifestyle in general. Research that focuses on the determinants and correlates of behaviours is important. This is because while many correlates appear to be intuitively obvious, at present they have mixed support from high quality research [ 3 ].

Four issues did not fit into the aforementioned categories. They were related to the theory of behaviour change, injury prevention, measurement of behaviours and the physical education in culture of movement. Objective measurement of behaviours was ranked highly and is thought to be a “necessary first step for conducting meaningful epidemiological surveillance, public health research and intervention research” [ 14 ] p.124.

Strengths and limitations

Unlike previously identified priority reports [ 11 , 13 – 15 ] this study employed a Delphi method to arrive at a more valid set of research priorities. Strengths related to the Delphi method include participant blinding, iterative data collection and controlled feedback between rounds. For example, the identities and responses of the experts were anonymised so that the identified research priorities could not be dominated by certain individuals [ 24 ]. Furthermore, the provision of controlled feedback allowed experts to individually consider their views in light of their panel’s collective opinion.

Other strengths related to the methodology were the use of criterion and purposive sampling methods. This procedure meant that all participants held a senior position in their respective organisations and had published in the study area. In addition, experts collectively represented every major world region and a wide range of discipline areas, affiliations and interests. This approach meant that the identified research issues were more likely to reflect the most important physical activity and sedentary behaviour issues facing the children and adolescents worldwide.

A novel component of this study was split-panel approach, which allowed comparisons to be made between the rankings given by the two expert panels. The experts from each panel were taken from the same population, given the same study information, answered identical online questionnaires and participated simultaneously and independently. One can therefore be confident that comparing the Round 3 rankings of Panel A and Panel B experts would provide valid measures of inter-panel agreement.

The weak intra-panel agreement was weak, which is likely a reflection of the natural variation of individual’s opinions and areas of interest within the broad study area. This weak agreement could also highlight the advantages of the methodology which retained anonymity and used an online mode of data collection. There were fewer pressures to conform to others opinions due to decreased likelihood of peer dominance and status. Evidence to reinforce confidence in the results is the strong to very strong (rho = 0.52–0.79) inter-panel agreement. While experts were invited from every United Nations sub-region (United Nations 2011), no experts from the following sub-regions took part: Southern Africa, Middle Africa, Caribbean, Eastern Europe, Australia, Central Asia and Western Asia. This was significant because many of these sub-regions are heavily involved in physical activity and sedentary behaviour research. Consequently, caution should be applied when recommending that the identified research priorities truly provide a global perspective. Nonetheless, these research priorities provide an international context from which priorities at the regional, national and local levels can be developed.

In addition the priorities were set for the broad area of child and adolescent physical activity and sedentary behaviour. Due to the generality of this topic, it may be that the research priorities are not relevant when conducting research into minority populations. For example, children and adolescents with disabilities may warrant different research issues not identified in this study.

Implications for research

We hope that the identification of a set of ranked research priorities may contribute to more co-ordinated international research. For example, research priorities can help inform post-graduate students regarding where the current evidence gaps exist. This may be especially helpful for researchers who reside in less developed or marginalised research regions. In addition, encouraging more guided research can help to conceptualise how findings can be used as a basis for policy decisions. Lastly, research priorities can help to direct valuable funding into priority areas and away from studies on over-researched or lower priority topics.

This study engaged two panels of study experts in a three-round Delphi communication procedure. The outcome of this procedure was the identification of a ranked set of 29 research priorities in child and adolescent physical activity and sedentary behaviour. For example, the top three ranked priorities were: developing effective and sustainable interventions to increase children’s physical activity long-term; policy and/or environmental change and their influence on children’s physical activity and sedentary behaviour; and prospective, longitudinal studies of the independent effects of physical activity and sedentary behaviour on health. We hope these research priorities will help inform the spectrum of future studies undertaken, guide post-graduate study choices, guide allocation of funding to priority areas and assist with policy decisions.

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Acknowledgements

The authors would like to acknowledge the Health and Use of Time Group at the University of South Australia.

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Lauren Gillis, Grant Tomkinson & Timothy Olds

Research Centre in Physical Activity, Health and Leisure, Faculty of Sport, University of Porto, Porto, Portugal

Carla Moreira & Jorge Mota

Ergonomics Unit, Rhodes University, Grahamstown, South Africa

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Department of Public Health Sciences, University of Hawaii at Manoa, Honolulu, HI, USA

Institute of Human Performance, The University of Hong Kong, Hong Kong, China

MRC Epidemiology Unit, Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK

Esther Van Sluijs

The Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK

Gareth Stratton

School of Physical and Health Education, Queen's University, Kingston, Ontario, Canada

University of the South Pacific, Laucala Campus, Suva, Fiji, Islands

Jeremy Dorovolomo

Physical Activity for Health Research Group, School of Psychological Sciences and Health, University of Strathclyde, Jordanhill, Glasgow, UK

Department of Physical Education, Sultan Qaboos University, Muscat, Sultanate of Oman

Physical and Health Education and Department of Psychology, School of Exercise Science, University of Victoria, Victoria, BC, Canada

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Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada

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The authors declare that they have no competing interests.

Authors’ contributions

The study was conceived by GT and TO. LG was primarily responsible for conducting the participant selection process and the three rounds of data collection. LG, GT and TO were each involved in data analysis. LG produced the first draft of the paper with all other authors providing sections and critically reviewing the paper. All authors approved submission.

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Gillis, L., Tomkinson, G., Olds, T. et al. Research priorities for child and adolescent physical activity and sedentary behaviours: an international perspective using a twin-panel Delphi procedure. Int J Behav Nutr Phys Act 10 , 112 (2013). https://doi.org/10.1186/1479-5868-10-112

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Received : 26 March 2013

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Published : 24 October 2013

DOI : https://doi.org/10.1186/1479-5868-10-112

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After reading this Research Topic, we hope readers will have a deeper understanding of and appreciation for how contemporary researchers use daily assessment methodologies for studying eating- and weight-related constructs in both children and adults, how modern technology can be exploited for this purpose, and the importance of studying these topics in naturalistic contexts. The compiled articles also highlight opportunities to assess antecedents as well as consequences of eating- and weight-related constructs at multiple time points, and to study community-based samples of youth, as well as clinical samples characterized by overeating or food refusal.

Overview of Contributions

Three contributions of this topic focus on original research in community-based samples. The paper by Verschueren et al. examined the temporal sequence of eating disorder symptomatology and identity formation in a sample of high school students. In this paper, the naturalistic approach is reflected in the longitudinal design comprising three annual measurement waves, which allowed demonstration of the developmental interplay between adolescents' identity formation and the development of eating disorder symptoms. Also prospective in nature, the paper by Debeuf et al. used a daily diary design in adolescents to investigate the relationship between stress and eating behavior and the moderating roles of emotion regulation and emotional eating. Findings confirm the association between daily stress and youngster's eating behavior. The results regarding the moderating role of maladaptive emotion regulation and emotional eating did not reach significance. A third study including a community-based sample, by Ha et al. , presents results from a pilot study exploring the influence of a food advertising literacy training on food choices in 8 to 13-year-old children. The training comprised four sessions of food advertising literacy training in 1 week, two of them held in the lab and two of them held at home reflecting the naturalistic element of this design. Interestingly, findings showed a reduction in the influence of taste attributes in the food decision making process of children after training. Taken together, these contributions used naturalistic designs to demonstrate that intra-personal factors such as identity formation and stress may explain youngsters' (pathological) eating behavior and that training children to cope with extra-personal factors such as food advertising may impact their food choices.

Other contributions of this topic focus on research in clinical samples. The paper by Lucarelli et al. describes the developmental course of infantile anorexia, a disorder that is recently defined as one of the subtypes of Avoidant-Restrictive Food Intake Disorder. The naturalistic approach of this paper is reflected by the four measurement points at which children and their mothers were assessed over time, more specifically, when children were ages 2, 5, 7, and 11 years. Although children's malnutrition somewhat improved over time, results demonstrated that a substantial proportion of the children (as well as their mothers) were still at a high risk of malnutrition and elevated psychopathological symptoms. Moreover, maternal factors appeared to be the best predictor of emotional/behavioral problems in the group of children who suffered from persistent malnutrition. The importance of considering a transactional view (i.e., including parental factors) when studying eating- and weight-related behavior in children is also an important theme in the commentary paper by Larsen et al. These authors elaborate on how general parenting styles may moderate the relation between weight-related parenting practices, and behaviors and weight outcomes among children. This commentary underscores the need for more research in the eating disorders and obesity fields that uses ecological momentary assessment. Finally, in the paper by Legenbauer et al. , a clinical sample of females with bulimia nervosa, binge eating disorder, and controls without eating disorders were recruited. Using an ecological momentary assessment design, evidence was found for a relationship between dysfunctional eating related cognitions and binge eating disorder and bulimia nervosa thereby providing support for cognitive models on eating disorders. This study's use of innovative technology may guide similar research in youngsters. In sum, using naturalistic designs, these papers cumulatively demonstrate how intra-personal factors such as dysfunctional eating related cognitions and extra-personal factors like parenting styles, practices, and parental psychopathology may be implicated in clinical feeding, eating and weight pathology.

Recommendations for Future Research

The importance of studying eating behavior from a transactional perspective.

The results of the included studies demonstrate that it is important to incorporate a transactional viewpoint when studying child and adolescent eating behavior. Although previous research in this area has already focused on examining the role of biological, psychological, and sociocultural factors in improving our understanding of eating behavior, most studies focus on one only of these levels in isolation from the others. However, Lucarelli et al. stress the importance of evaluating maternal psychopathogological symptoms which may contribute to the onset, severity, and persistence of children's disordered eating over time. Moreover, as Larsen et al. argue, more general parenting practices should be taken into account as an important moderator in the link between feeding practices and eating and weight related outcomes in children. Thus, future research may include a comprehensive approach in which factors that can be situated on different levels are examined together.

The Importance of Taking Into Account Developmental Tasks

Next, when studying eating behavior in children and adolescents, it seems crucial to acknowledge the developmental tasks youth are facing, as well as the complex dynamic relation between development and eating problems. For example, as demonstrated by Lucarelli et al. , problematic eating behavior that occurs at very young ages influences many aspects of children's development, such as emotional and behavioral functioning. These authors suggest that it is important in future research to measure the effects of malnutrition on the onset of puberty. Thus, it will be important to investigate not only how stress related to developmental tasks may influence eating behavior, but also the inverse of how eating behavior may influence development. This point is also underscored by Verschueren et al. , who reported a bidirectional relation between problems with identity formation, an important developmental task during adolescence, and pathological eating behavior in adolescents.

Additional Insights From Real Time Approaches

Although from a developmental psychopathology perspective, longitudinal studies opportunities to tease apart timing and temporal sequencing of risk factors for (maladaptive) eating behaviors, the use of real-time approaches may offer additional insights into momentary predictors or correlates of eating behavior in children and adolescents. In the study of Debeuf et al. , a daily diary design showed that daily stress is associated with trajectories of eating motives over 7 consecutive days of assessment. This adds to our understanding of momentary associations between stress and eating behavior as fine-grained analysis are often lacking so far. In the study by Legenbauer et al. , an EMA-approach with a signal-sampling and event-sampling design over a period of 48 h was able to demonstrate how cognitive content exerts an impact on eating behavior in daily life. Although future research should examine whether the findings in adults can be generalized to younger age groups, this study was the first to show the impact of specific patterns of dysfunctional eating-related cognitions for different ED diagnostic categories using an EMA design. Moreover, as evidence from longitudinal studies and ecological momentary assessment designs increase our understanding about how affect, cognition, and behavior interact and unfold over time, new and emerging theoretical models can be developed to inform interventions, including those delivered in real time. For example, Ha et al. targeted a sociocultural variable (food advertising) and delivered training in both a controlled laboratory environment and in the children's naturalistic environment. With their training, they were able to influence food choice behavior in children between 9 and 13 years old.

We conclude that the papers of this Research Topic focus on research questions that advance the field and guide future research on which (combination of) factors may be studied to enhance insight in children and adolescent's normal and pathological eating behavior. Furthermore, the challenging research designs that are used throughout the different papers offer insight on how innovative research questions may be studied in children's and adolescents' everyday environment.

Author Contributions

SV and LG: contribution to manuscript review and responsible for writing the first draft of the current editorial. AG, CE, and CB: manuscript review.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Keywords: eating behavior, children, adolescents, EMA, overeating, foodrefusal

Citation: Verbeken S, Goldschmidt AB, Evers C, Braet C and Goossens L (2019) Editorial: Eating Behavior Research in Children's and Adolescent's Naturalistic Environment. Front. Psychol. 10:2139. doi: 10.3389/fpsyg.2019.02139

Received: 16 July 2019; Accepted: 04 September 2019; Published: 19 September 2019.

Copyright © 2019 Verbeken, Goldschmidt, Evers, Braet and Goossens. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Sandra Verbeken, sandra.verbeken@UGent.be

This article is part of the Research Topic

Eating Behavior Research in Children’s and Adolescents' Naturalistic Environment

Research in child and adolescent anxiety and depression: treatment uncertainties prioritised by youth and professionals

Brynhildur Axelsdóttir Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Lise Mette Eidet Roles: Data Curation, Formal Analysis, Investigation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ragnhild Thoner Roles: Data Curation, Investigation, Project Administration, Validation, Writing – Review & Editing Sølvi Biedilæ Roles: Formal Analysis, Investigation, Validation, Writing – Review & Editing Ingrid Borren Roles: Data Curation, Formal Analysis, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Mari Elvsåshagen Roles: Validation, Writing – Review & Editing Kristine Horseng Ludvigsen Roles: Validation, Writing – Review & Editing Astrid Dahlgren Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

child and adolescent development research paper

This article is included in the Developmental Psychology and Cognition gateway.

child and adolescent development research paper

This article is included in the Health Services gateway.

Anxiety, Depression, Children, Adolescents, Research priorities, Consensus.

Revised Amendments from Version 1

We wish to thank the reviewers for valuable comments on the manuscript. The main differences compared with the previous version are: We have changed the title of the paper due to discrepancies in our approaches and of the James Lind Alliances. We have also tried to highlight the differences between the two approaches in methods and discussion and have revised the manuscript to make this clearer. We have rephrased the objectives to make it clearer. We have given a definition on key concepts such as treatment, outcomes, research uncertainties and research priorities, in the introduction, for clarification.

See the authors' detailed response to the review by Judith Borghouts See the authors' detailed response to the review by Kristina Staley

Introduction

Anxiety and depression are common mental disorders in adolescence. Anxiety is characterised by restlessness or nervousness, poor concentration, and irritability. Depression is characterised by persistent low mood, loss of interest and enjoyment. 1

The prevalence of anxiety and depression increases during adolescence, and the comorbidity between these diagnoses is high among young people. 2 Almost 10% of adolescents will meet the criteria of an anxiety disorder. 3 The one-year prevalence rate of adolescent depression is estimated to be 5.6%. 4 In Norway, the prevalence of diagnosed depression in girls 15-17 years has increased from 1.5% to 2.3% from 2010-2013. 5

Both anxiety and depression in adolescence are associated with functional impairment and can affect academic achievement, which may have a lifelong effect on employment. 6 , 7 According to the WHO’s Global Burden of Disease, the leading cause of years lost due to disability (YLDs) for both genders 10-24 years is unipolar depressive disorders. 8 The serious consequences of anxiety and depression in adolescence highlights the need for efficient interventions, and the importance of including perspectives of their own experiences.

Currently, recommended treatments for anxiety and depression are psychological therapy, pharmacotherapy, or a combination of both. 9 – 11 By “treatment” we refer to any action or intervention used to change an aspect of a young person’s mental health, that being medicines or school-based interventions. Such treatments may also have an impact on other aspects of the young person’s life that may be important to consider in research. There are also many other treatments used for both anxiety and depression. Some based on well-founded scientific research while others can be regarded as treatment uncertainties, as there is uncertainty about the effectiveness of the treatment. Such uncertainties are either consequences of a lack of research, or that the research is not adequately performed and therefore the evidence is weak. 12 A starting point for new research on treatments should be to identify treatment uncertainties (evidence gaps), in order to shape future research priorities. 13 , 14

Evidence gaps can be prioritised through user involvement. 20 The purpose of user involvement in research is to ensure that research becomes as relevant to the population in question as possible. When initiating research on treatment effects, it has not always been common practice to obtain the perspectives of patients, clinicians or carers. 15 , 16 Thus, important research questions remain unanswered, and research funding may not be used where most needed. 17 A recent systematic review, based on 83 studies involving 15,722 participants, demonstrated how uncommon it is to involve children and their caregivers in setting research priorities in the field of childhood chronic disease. 16

A recent publication by Chevance et al ., 18 published in 2020, described a similar process with adult participants in an international survey, identifying outcomes for depression that matter to patients, informal caregivers, and health-care professionals. Another process of developing an Overall Paediatric Health Standard Set [OPH-SS] of outcome measures which matters to young people and their families, internationally, was also published in 2020. 19 The current study complements both papers, as this paper looks at both children and adolescents, as well as desired research priorities in terms of treatments, as well as outcomes.

We recently produced two overviews of systematic reviews on the effects of interventions for anxiety and depression in children and young people, respectively. 10 , 11 This left us with a momentum for inviting young representatives from these populations (youth) and those providing mental health services to identify and prioritise research uncertainties associated with these conditions.

The objective of this study was to a) to obtain suggestions from youth and clinicians of treatments and treatment outcomes not identified in our overviews of systematic reviews on depression and anxiety. b) to have the two groups prioritise the ten most favoured suggestions and subsequently vote on their ranking in preferred order of importance.

REK, Regional Committees for Medical and Health Research Ethics, Norway was contacted for approval of the project. They concluded that the project did not require their approval as there was no registered personal data. All information was collected through Nettskjema (a web-based survey system), ascertaining a high level of data security and safety.

All respondents were given information about the purpose of the study and how the results would be managed and presented and were informed that by responding to the survey, they consented to participation in the study. The questionnaire was anonymous and once submitted, the information could not be traced back to the respondent.

1. Document analysis : identification of interventions and outcome measures used for treating children and adolescents with anxiety and depression in two previously published overviews of systematic reviews. 10 , 11

2. Mapping study (surveys) : we encouraged identification by clinicians and patient representatives (children and adolescents who have, or have had, anxiety or depression) of additional priorities outside of those previously identified.

3. Consensus process : prioritisation of research uncertainties by clinicians and patient representatives.

Our approach was partly inspired by a method developed by the JLA. 20 The method involves patients and clinicians in suggesting research priorities. The method is designed to raise awareness of important evidence gaps, with the potential of influencing new research initiatives. 15

The stages of the prioritisation process are outlined in Figure 1 .

Figure 1. Flow chart of the method process.

Document analysis: identification of interventions and outcomes in existing research.

In two recently published overviews of systematic reviews, we have summarised the effects of interventions for anxiety and depression in children and adolescents. 10 , 11 Although these publications are in Norwegian, the methodology of the review process have been published in registered protocols and is available in English through the PROSPERO database; CRD42020159883 (depression) and CRD42020159884 (anxiety). To provide context to this paper, we briefly describe the inclusion criteria and search strategy of the reviews here. Both overviews adhered to the PRISMA guidelines 21 and to the following inclusion criteria:

Publications: Systematic reviews published 2012 and later, fulfilling the DARE-criteria .

Language: English, Norwegian, Danish, or Swedish.

Participants: Children and adolescents under the age of 18, with or without an identified risk of developing mental health problems or those who have already developed these problems.

Intervention: Any intervention aimed at preventing or reducing mental health problems or welfare interventions, including psychological therapy, pharmaceutical interventions, psychosocial interventions etc.

Comparison: Other relevant interventions, treatment as usual (TAU), no treatment or wait list.

Outcomes: All outcomes of mental health problems and child welfare evaluated in children and adolescents, including other health outcomes, quality of life, function, use of health care, attitudes and adverse effects of interventions.

The search for reviews that were included in these two overviews was largely based on the IN SUM database and was performed in April 2018, with an updated search in December 2018. IN SUM is a recently developed database of systematic reviews of the effects of interventions relevant to children and young people’s mental health and welfare. The database indexes systematic reviews from the following databases: Cochrane Database of Systematic Reviews, Campbell Library, PsycINFO, Medline, Embase, Web of Science, Database of Abstracts of Reviews of Effects (DARE) and Evidence-Based Mental Health. IN SUM is continuously updated monthly with the latest systematic reviews. In addition to IN SUM, we hand searched the websites of the Norwegian Institute of Public Health, the Swedish Agency for Health Technology Assessment and Assessment of Social Services, the Danish Health Authority for Systematic Reviews and the National Institute for Health and Care Excellence for evidence-based guidelines, UK. For complete search strategies see Extended data. 28

The first author (BA) extracted all interventions and outcomes reported in these two overviews in a simple document analysis and second author (AD) double-checked the extraction.

Mapping study (survey): identification of uncertainties in research

We created three surveys, each including four questions asking the respondents to report what treatments and outcomes ought to be topics for research, in their opinion. For each question, the recipients were presented with a list of the treatments and the outcomes already addressed in existing research (see Table 1 , Table 2 ), based on the two overviews of reviews. 10 , 11 The three surveys were distributed to clinicians and users as an electronic questionnaire via Nettskjema.

Table 1. List of treatments and outcomes of anxiety based on existing research. **

* The quality of the evidence is graded as low or very low.

** Treatments and outcomes in 2018, more treatments and outcomes are described in the 2021 update.

Table 2. List of treatments and outcomes of depression based on existing research **

** Treatments and outcomes in 2018, more treatments and outcomes are described in the 2020 update.

The survey questions had an open answer option (see Extended data 28 ). Respondents can be unfamiliar with research, and we therefore considered it more appropriate to let respondents formulate their need for research in their own words. 20 The purpose of the surveys was to collect suggestions for research uncertainties, consequently, the sample did not need to be representative. 20 Instead, we used convenience sampling to recruit the participants. Anyone living in Norway with experience and understanding of living with anxiety or depression was eligible to participate in the identification of uncertainties. This included children and adolescents with anxiety and/or depression, carers, family members and friends. Also, healthcare, and social care professionals who had worked with children and adolescents living with the conditions were eligible. We strived to ensure that professionals working in different levels in health and welfare services were represented, as well as users. No demographic data were collected as it is not a part of later analysis in priority setting partnerships. In contrast to the principles of JLA the priority lists in the current paper were not rewritten or rephrased as questions. Instead, the lists consist of keywords of outcomes and treatments. The background for this decision was related to the scope of the project; to have the participants choose among suggestions of treatments and treatment outcomes identified as evidence gaps. Our narrow scope did not require full phrased questions.

The first survey was sent on 22 nd February 2019, to our institution's contacts working with children and young people's mental health in the municipalities (Eastern and Southern Norway), including employees in child welfare institutions/orphanages, special education teachers working in schools, child welfare services, child welfare guards, family protection offices, refugee and immigration departments.

The second survey was distributed on 19 th March 2019, to professionals working in the specialist mental health service for children and adolescents. These were also contacted through our networks. In addition, we recruited respondents in collaboration with the Norwegian Association for Children and Young People’s Mental Health (NBUP) and from our institution’s newsletter.

The third survey was distributed on 25 th April 2019, to children and adolescents having personal experiences with depression and/or anxiety, as well as to their carers, in collaboration with the Norwegian organisation for youth mental health, Mental Helse Ungdom (MHU). We also sought to recruit respondents through social media platforms of our institution, e.g., Facebook and Instagram. We posted a link of the survey on the platforms 2 nd August 2019, with an invite to eligible participants to complete the survey.

Content analysis

1) interventions for anxiety

2) interventions for depression

3) outcomes of interventions for anxiety

4) outcomes of interventions for depression

Consensus process: prioritisation of research uncertainties

Preparations for the consensus process

The next step was to prepare for the consensus process, where selected professionals and users were asked to prioritise the suggested research uncertainties. There is no gold standard for conducting a consensus process. However, group composition can have an impact and may lead to different judgements. 22

A multi-disciplinary team of professionals were recruited through our networks through convenience sampling. We received help recruiting clinicians from a local child and adolescent psychiatric outpatient clinic. Our contact person there, reached out via e-mail on 21 st August 2019, to clinicians with a request to participate in the consensus process. The criteria were clinicians who work, or have worked, with children and adolescents with anxiety or depression. A variety of professionals from different backgrounds and working at different levels of health and welfare services (such as psychologists, psychiatrists, physiotherapists, nurses, educators, and health nurses) came forward. Seven clinicians from the specialist mental health services and four from the municipal health services accepted the invitation to participate. For recruitment of user representatives, we contacted the Assistant General Secretary of MHU. She reached out via e-mail on 15 th September 2019, to their members of staff and youth with experience of the conditions, and twelve participants accepted the invitation.

Once recruited, we received contact information of 10 participants proposed by the assistant general secretary of the organisation on October 10 th ,2019. We emailed the four lists with the suggested interventions and outcomes for anxiety and depression, respectively to the participants. They were individually asked to put the suggestions in ranked order, by selecting only 10 options that were assigned 1 point each. For the three most important options we asked them to assign these 2 points. This resulted in the first drafts of prioritised lists of interventions, and outcomes of interventions, for anxiety and depression.

The results from this pre-prioritisation were summarised by two members of the research team (AD and BA), and four lists were created with the highest-ranking suggestions. The two overviews of systematic reviews documented which treatments and outcomes that lacked or had weak scientific evidence. 10 , 11 The participants of the workshops were made aware of this before conducting the interim prioritisation, also enabling them to prioritise among those.

For practical reasons, it was not possible to host a shared workshop for professionals and users. Instead, separate workshops were held.

When conducting consensus processes, the criteria for establishing priorities should be applied using a systematic and transparent process. 22 Furthermore, group discussions should follow some basic rules that the participants have chosen jointly. Participants should listen to each other and show respect for each other’s ideas. 20

We applied the Nominal Group Technique for both workshops. This approach is characterised as a structured method for group brainstorming, encouraging discussion and facilitating agreement on the relative importance of issues in question. The process should be led by someone who is not part of the project group, who has no research background. The person will, therefore, have a more neutral role in the process. It is essential that the entire process has openness and justice as guiding principles. 20 For this study, we invited an experienced expert in consensus processes to facilitate and host the workshops (RT), the rest of the team played the part of silent observers and handled all practical needs (LME, SB, AD, and BA).

The first workshop was held at our organisation’s location in Oslo, Norway on 26 th September 2019, from 9:00 am to 3:00 pm. Three members of the project group attended the workshop in addition to the consensus host (LME, RT, AD, and BA). Eight out of 11 clinicians were able to participate in the workshop: psychologists, special educators, clinical social workers, and a physician. Three clinicians were unable to attend for various reasons such as sickness etc.

For the second workshop, we recruited youth from MHU. The workshop took place in their location on 11 th November 2019, from 9:00 am to 3:00 pm and was administrated in the same way as the workshop with the clinicians. Ten out of 12 invited youth were able to participate in the priority setting, and three members of the project group facilitated the workshop (RT, SB and LME). Two participants were unable to attend.

After formal introductions and light refreshments, the participants received an introduction for one hour, to the principles of research, systematic reviews, and evidence-based practice. They were also informed about the purpose and agenda of the day. Thereafter, the participants were divided into small groups based on their professional background, age and in the workshop with the youth, earlier experience with anxiety and/or depression. For each topic, the participants were then mixed in different groups with at least three participants in each group. This part of the workshops lasted for four hours with a half an hour lunch break.

The groups were assigned the task of selecting 10 options and prioritising these for each topic. The groups worked independently but were facilitated by the host when necessary. Other members of the project group were silent observers, taking notes. At the workshop with the professionals, the host used images of children and adolescents with depression and anxiety during this process, as a reminder of the perspectives of the target group involved.

The final hour of the workshops included individual prioritising. All four lists were entered into a voting app by one of the members of the project group and each participant was asked to anonymously rank the final top ten priorities per list. This resulted in four top ten lists of priorities ranked in order by their perceived importance [see Underlying data 28 ].

Summary of existing research

The results of the document analysis were collated and made into 4 lists. In the surveys, the respondents were presented with these lists (see Table 1 and Table 2 ). Note that for several of these treatments and outcomes, the quality of the evidence is graded as low or very low (marked with * in the tables). Therefore, these could still be suggested as research uncertainties.

Results of the surveys: identified research uncertainties by clinicians and patient representatives

Overall, 674 respondents submitted a total of 1267 research suggestions in the three surveys. After content analysis, 379 unique suggestions (134 treatments for anxiety, 90 treatments for depression, 84 outcomes for anxiety and 71 outcomes for depression), were sent for ranking via e-mail to the clinicians and youth participating in the workshops.

In response, the clinicians ranked and shortened the list to 70 suggestions. The youth ranked and shortened it to 51 suggestions. For full detail of the results of the process see Figure 2 .

Figure 2. Flow chart of full process with results.

Prioritisation of research uncertainties.

Eight clinicians participated in the first workshop: psychologists, special educators, clinical social workers, and a physician. Two of the clinicians worked in the mental health services in the municipalities, and the six others worked in the specialist mental health service for children and adolescents.

The 10 youth participants from MHU participated in the second workshop. See detailed results of the process in Figure 2 and the final results of the workshops priority setting in Tables 3 , 4 , 5 and 6 .

Table 3. Prioritised treatments for anxiety.

Table 4. prioritised outcomes of interventions for anxiety., table 5. prioritised treatments for depression., table 6. prioritised outcomes of interventions for depression..

This study has demonstrated essential research priorities in terms of treatments that should be evaluated and outcomes that should be measured according to youth and clinicians. The top ten lists reflect both similarities and differences in what is considered important by the clinicians and the youth.

Clinicians ranked family and parent-based interventions as their top priority for both lists of treatments (anxiety and depression). Youth also ranked family and parent-based interventions as their top priority for treatments of anxiety. Functioning in daily life, and in the family are amongst the top ten treatment priorities by both groups. Other common priorities important to both clinicians and youth are increased cooperation between mental health services and schools, and multi-disciplinary cooperation.

Top priority for depression treatment among the adolescents, were easy access to treatment. The clinicians also emphasize increased cooperation between mental health services and schools, as well as group treatment and school-based interventions. Thus, the clinicians seem to focus on strengthening the environment around the youth to a greater extent than the adolescents do. School-based therapies, school functioning and access to a school psychologist are also similar priorities. The youth seem, however, to display a greater need for interventions for forming relationships, resilience groups, and life coping strategies, which is not mentioned at all in the clinicians’ list.

A unique priority suggested by the youth is therapy for transgender people, specifically regarding anxiety. This may demonstrate a difference between generations regarding the focus on gender identity and the need to cope with such issues.

On the lists of outcomes of interventions for both conditions, functioning in daily life, in the family, and at work were ranked very high by both the clinicians and the youth, as well as friends and social activities. Other important common suggestions are long-term follow-up of interventions, treatment satisfaction and user involvement. However, it is worth noting that the outcomes most important for the adolescents, for both anxiety and depression, were highly subjective/internal outcomes like resilience, faith in oneself, life skills, identity, daily life functioning and trust in other people. In contrast, the clinicians ranked friends and social activities on top of both lists, while this suggestion was not found on the adolescent’s lists. Thus, the clinicians seem to view the context the youth is in as more important than the youths do themselves, who to a greater extent emphasize personal coping skills, like faith in oneself and resilience. This difference may possibly tell us that contextual factors (friends, school or dropping out of school) are regarded less important for individuals struggling with mental health challenges, and that inner personal growth and mastery are key factors for these young people. The clinicians may, on the other hand, have been thinking more in terms of outcomes known to be preventive factors (like friendship and social structures). 23

Clinicians rated adverse events as important for both conditions. The lack of research of unwanted effects of treatments for depression in children and adolescents has recently been demonstrated in a mapping of systematic reviews. 24 Both the clinician’s views and Eidet’s article 24 point to the need for more research, and thus address adverse events in these treatment groups as an important evidence gap.

Strength and limitations

This study builds on rigorous qualitative and quantitative methods, including two extensive systematic reviews on the effects of treatments for anxiety and depression. To our knowledge this is also the first mapping study in Norway exploring research uncertainties related to treatments and associated outcomes for anxiety and depression.

The current study is in line with evidence-based practice as it is defined as ‘The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient’. 25 Evidence-based practice highlights the consideration of the patient’s opinions in choice of treatment (alongside clinical opinions and research-based methods), and the current project contributes along these lines also, by letting patients voice their concerns regarding research gaps. We have integrated the best research evidence and involved clinical expertise both in the surveys and the workshop with clinicians. Furthermore, we have included the personal and unique values of the patients. All of these should be a part in any decision-making process concerning research and treatments for children and adolescents.

There has been increasing attention to patient-reported outcomes during recent years. Outcomes should be relevant and important to both patients, caregivers, health care professionals and other stakeholders making decisions about health care. 26 , 27 For discovering what outcomes are important to patients and health care professionals, consensus processes, as demonstrated in this study, are vital. This study is especially important because we succeeded in including the views of young people, considering how rare patient and family engagement are in research priority setting. 16

The importance of user involvement is demonstrated in feedback from participants in both workshops:

“ It feels very meaningful to be able to contribute to this project on behalf of all the patients I have been in contact with ”.

“ Children and adolescents should always be involved in decision-making, not just clinicians ”.

Although the current study was partly inspired by the JLA framework there are some major discrepancies that need to be addressed. Firstly, we were unable to arrange a joint priority setting partnership between the two groups. Secondly, our study resulted in four different lists of priorities as it covers both treatments and treatment outcomes for anxiety and depression. Third, the lists in the current study consist of keywords and not fully phrased questions, due to the narrower scope aiming at extracting specific treatments and outcomes.

The limitation of consensus processes should be acknowledged. The current priorities are based on individual’s or groups’ point of views and their subjective opinions. We might, in our consensus process with a different pool of people in a different situation, reach a different result. 20 However, involving people together in a quality discussion to reach genuine consensus is of great value, as it represents an important contribution to the debate on research priorities. Bringing people together in a workshop enables them to exchange knowledge and information and make decisions in their meetings with the health services, based on a wider set of experiences.

Initially we intended to host only one priority setting workshop with both clinicians and the youth, however we were unable to find an appropriate date suitable for both groups. Although hosting a shared workshop would have had several benefits, we also found it useful to keep the groups separated. We were able to avoid challenges, such as ensuring the choice of participants being balanced, avoiding domination by one person, and reaching consensus when there may have been disagreement. The two separate processes allowed us to compare the results of professionals and the youth. It also provided a safe zone for professionals and the youth, where especially the latter could speak more freely and perhaps avoid feeling ‘led’ to conclusions by clinicians whom they perhaps could see as authority figures with more experience than themselves. However, keeping the groups separate meant that we also missed the opportunity of cross-fertilization of ideas and nuancing of perspectives, that mixing professionals and users may have contributed to.

We have demonstrated the possibility to develop an agreed four top ten lists of research priorities for anxiety and depression in children and adolescents, with contribution from youth experiencing anxiety or depression as well as clinicians. The perspectives from their individual lists, have the possibility to influence the research agenda according to the needs and opinions of both clinicians and the patients themselves.

Data availability

Underlying data.

Harvard Dataverse: Priorities for research in child and adolescent anxiety and depression: a priority setting partnership with youth and professionals https://doi.org/10.7910/DVN/UQPYVT . 28

• Coding_priorities from participants_Clinicians_final_25.09.2019.tab

• Coding_Priorities_Adolescents_Final_07.11.2019.tab

Extended data

• Tables 3-6 (in Norwegian, pdf.)

• Appendix I (Copy of survey no.1, no.2. and no.3.)

• IN SUM Search strategies_2021.pdf

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver ( CC0 1.0 Public domain dedication ).

Acknowledgements

We would like to thank the following for helping recruiting participants to the workshop with clinicians: Signe Revold, Akershus University Hospital, Morten Grøvli, Akershus University Hospital and a member of the RBUPs board and Kaja Kierulf, centre manager of RBUP. We would like to thank Thisbe Verner-Carlsson and Aida Tesfai at the Norwegian Mental Health Youth (Mental Helse Ungdom) for distributing the survey no. 3 and recruiting participants to the second workshop with the youth. We are grateful to NBUP, the Norwegian Associations of Mental Health Services for Children and Adolescents for help of distributing the survey no. 2. We also would like to thank our colleagues at RBUP, Siri Saugestad Helland, Kristian Rognstad and John Kjøbli for assistance with the first survey, distributed to persons working with children and young people's mental health in the municipalities. Finally, and most importantly, we would like to thank all the participants of both workshops.

Comments on this article Comments (0)

Open peer review.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Academic researcher in Digital Mental Health and Human-Computer Interaction with 10 years of experience in quantitative and qualitative research.

Is the work clearly and accurately presented and does it cite the current literature?

Is the study design appropriate and is the work technically sound?

Are sufficient details of methods and analysis provided to allow replication by others?

If applicable, is the statistical analysis and its interpretation appropriate?

Are all the source data underlying the results available to ensure full reproducibility?

Are the conclusions drawn adequately supported by the results?

I cannot comment. A qualified statistician is required.

Reviewer Expertise: I have worked on over a dozen JLA PSPs as an Information Specialist and have worked in the field of patient and carer involvement in research for over 20 years

Author Response 04 May 2022 Brynhildur Axelsdottir , Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, 0484, Norway 04 May 2022 Author Response 1.This paper reports on a priority setting exercise which has drawn on the JLA approach but has changed so far from it that I question whether to make the links ... Continue reading 1.This paper reports on a priority setting exercise which has drawn on the JLA approach but has changed so far from it that I question whether to make the links is appropriate. For example I'd challenge the use of the term priority setting partnership in the title. The approach in this paper differs from the JLA process in two main ways: Categorising the uncertainties collected via survey of young people and professionals. In a JLA process the Steering Group, a mix of professionals and affected patients/carers, are heavily involved in interpreting the responses to generate a list of uncertainties using phrasing and language that summarise the responses. The aim is always to stay faithful to the original responses. In this paper the researchers have drawn out interventions and outcomes as separate lists - not whole questions. I do not understand the rationale for this and would like a clearer explanation in the article. As they have identified, the language used and the priority given to different ways of understanding the issues makes it difficult to combine the youth and professionals' priority lists of interventions/outcomes. In the JLA process, this is done in the partnership of the Steering Group to reach a shared agreement of the list of topics to be prioritised, a shared understanding of what these mean so that people from all perspectives can understand and prioritise the shared list. Furthermore, I'd like the authors to comment on how the prioritised lists of interventions and outcomes might be used to shape future research. Response: We thank the reviewer for pointing this out and we acknowledge the differences of our study and the James Lind Alliance framework. We have therefore changed the title of the article. In addition, we have elaborated on these differences in methods and discussion. As to the comment on how the prioritised lists of interventions and outcomes might be used to shape future research, we strongly believe that researchers can be inspired to see what interventions lack evidence (based on evidence gaps identified by the overviews of systematic reviews) as well as what outcomes should be measured when designing new studies on these subjects, based on the participants’ priorities. To highlight the desired interventions and outcomes of users and clinicians may hopefully bring awareness to researchers regarding the needs of these groups – potentially enhancing shared decision-making in future studies. 2. The final workshop - it is essential that all parties come together and reach a shared agreement of the Top Ten. It would seem important to find a date for such a meeting that all could attend rather than have separate meetings. And for the group discussion to inform the prioritised list rather than individuals voting on an app. So in general there seems to have been limited shared decision-making at each of the stages of this process which makes me question whether this was genuinely a partnership or actually different groups prioritising topics separately. This is what makes it very different to the JLA process. Response: There is no gold standard to priority setting of research uncertainties. JLA has however developed an extensive experience and evidence base in this area which has inspired our efforts. We acknowledge that our approach differs from that of the JLA. We have revised our manuscript to make this clearer and have made it explicit which of the methodological choices recommended by JLA we have applied. We have also added a paragraph to the discussion about the potential limitations and strengths of the choices we made. As the reviewer points out, the JLA is not a set of methods but suggests some principles and values that should be considered. The experts and patients taking part in our study were not able to meet in the same day for the consensus workshop, and thus our process resulted in two separate sets of priority lists. Although the resulting lists were not created in a partnership of patients and providers, the results of these two consensus processes provides the opportunity to compare the differences in priorities by patients and providers. This may have brought additional – and potentially valuable – information and possibly cover more evidence gaps. Even though our process differs from that of JLA, we have used methods of high quality, including basing our process on high-quality systematic reviews, including both qualitative and quantitative feedback from experts and patients, and applying a recognized consensus-process methodology. We believe that the priorities-lists resulting from our study is an important contribution to this research and should be used to shape future research efforts. 3. The outputs are quite distinct from those of a JLA process - so I suggest the authors refer to the JLA perhaps once, and instead describe their own process and the rationale for how they have approached it, what they expect the impact to be, and their perceived value of their outputs. Different does not mean better or worse - this is a different process to the JLA and may have strengths or weaknesses as a result. Perhaps these could be explored in the article. The JLA is not a set of methods, but the principles and values that underpin partnership working are absolutely key to it and these are not described in the approach in this paper and I therefore recommend that the suggestions that this process is linked to the JLA approach are reduced. Response: We accept and agree that our process varies from the one of JLA and we have erased the sentence of JLA in the abstract and reframed sentences where we mention JLA in the method section, as well as reduced the numbers of references to the JLA guidance. We have elaborated on strengths and weaknesses of the current study in the discussion and added some clarifications in the introduction about the differences between our approach and the JLA method. We would like to thank the reviewers for their valuable comments. 1.This paper reports on a priority setting exercise which has drawn on the JLA approach but has changed so far from it that I question whether to make the links is appropriate. For example I'd challenge the use of the term priority setting partnership in the title. The approach in this paper differs from the JLA process in two main ways: Categorising the uncertainties collected via survey of young people and professionals. In a JLA process the Steering Group, a mix of professionals and affected patients/carers, are heavily involved in interpreting the responses to generate a list of uncertainties using phrasing and language that summarise the responses. The aim is always to stay faithful to the original responses. In this paper the researchers have drawn out interventions and outcomes as separate lists - not whole questions. I do not understand the rationale for this and would like a clearer explanation in the article. As they have identified, the language used and the priority given to different ways of understanding the issues makes it difficult to combine the youth and professionals' priority lists of interventions/outcomes. In the JLA process, this is done in the partnership of the Steering Group to reach a shared agreement of the list of topics to be prioritised, a shared understanding of what these mean so that people from all perspectives can understand and prioritise the shared list. Furthermore, I'd like the authors to comment on how the prioritised lists of interventions and outcomes might be used to shape future research. Response: We thank the reviewer for pointing this out and we acknowledge the differences of our study and the James Lind Alliance framework. We have therefore changed the title of the article. In addition, we have elaborated on these differences in methods and discussion. As to the comment on how the prioritised lists of interventions and outcomes might be used to shape future research, we strongly believe that researchers can be inspired to see what interventions lack evidence (based on evidence gaps identified by the overviews of systematic reviews) as well as what outcomes should be measured when designing new studies on these subjects, based on the participants’ priorities. To highlight the desired interventions and outcomes of users and clinicians may hopefully bring awareness to researchers regarding the needs of these groups – potentially enhancing shared decision-making in future studies. 2. The final workshop - it is essential that all parties come together and reach a shared agreement of the Top Ten. It would seem important to find a date for such a meeting that all could attend rather than have separate meetings. And for the group discussion to inform the prioritised list rather than individuals voting on an app. So in general there seems to have been limited shared decision-making at each of the stages of this process which makes me question whether this was genuinely a partnership or actually different groups prioritising topics separately. This is what makes it very different to the JLA process. Response: There is no gold standard to priority setting of research uncertainties. JLA has however developed an extensive experience and evidence base in this area which has inspired our efforts. We acknowledge that our approach differs from that of the JLA. We have revised our manuscript to make this clearer and have made it explicit which of the methodological choices recommended by JLA we have applied. We have also added a paragraph to the discussion about the potential limitations and strengths of the choices we made. As the reviewer points out, the JLA is not a set of methods but suggests some principles and values that should be considered. The experts and patients taking part in our study were not able to meet in the same day for the consensus workshop, and thus our process resulted in two separate sets of priority lists. Although the resulting lists were not created in a partnership of patients and providers, the results of these two consensus processes provides the opportunity to compare the differences in priorities by patients and providers. This may have brought additional – and potentially valuable – information and possibly cover more evidence gaps. Even though our process differs from that of JLA, we have used methods of high quality, including basing our process on high-quality systematic reviews, including both qualitative and quantitative feedback from experts and patients, and applying a recognized consensus-process methodology. We believe that the priorities-lists resulting from our study is an important contribution to this research and should be used to shape future research efforts. 3. The outputs are quite distinct from those of a JLA process - so I suggest the authors refer to the JLA perhaps once, and instead describe their own process and the rationale for how they have approached it, what they expect the impact to be, and their perceived value of their outputs. Different does not mean better or worse - this is a different process to the JLA and may have strengths or weaknesses as a result. Perhaps these could be explored in the article. The JLA is not a set of methods, but the principles and values that underpin partnership working are absolutely key to it and these are not described in the approach in this paper and I therefore recommend that the suggestions that this process is linked to the JLA approach are reduced. Response: We accept and agree that our process varies from the one of JLA and we have erased the sentence of JLA in the abstract and reframed sentences where we mention JLA in the method section, as well as reduced the numbers of references to the JLA guidance. We have elaborated on strengths and weaknesses of the current study in the discussion and added some clarifications in the introduction about the differences between our approach and the JLA method. We would like to thank the reviewers for their valuable comments. Competing Interests: No competing interests were disclosed. Close Report a concern

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