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Research problem and specific questionsA stepped-care approach can lead to more effective care, reduced costs and work burden for mental health professionals. However, few models have been evaluated for children with externalizing behaviors (Oppositional Defiant Disorder, Conduct Disorder). These youth are at higher risk for continuous aggressive behaviors, academic failures, and mental health problems. Treatments mainly provide low to moderate treatment effects and the knowledge of change mechanisms is not satisfying, pointing towards a need for improved treatments. In this project, we aim to evaluate the effects, costs, scalability and acceptability of a stepped care model for families with a child with externalizing behaviors.Data and methodThis study uses a mixed-methods-design, with evaluations directly after treatment and after 6 months. The first step in the stepped care model is a digital parent intervention at selective-indicated preventive level (families with children 8-16 years at risk for/with oppositional, aggressive behavior

N=750) where an AB multiple baseline informs about changes over time. The second step is individual youth/parental treatment based on Cognitive Behavior Therapy (CBT) and virtual reality (VR) where families whose children still show signs of externalizing behaviors after the parent intervention are randomized to youth or parent CBT with/without VR. The evaluation will provide information on changes in children’s externalizing behaviors, well-being and parental strategies, as well as weekly measurements of change mechanisms will add to the understanding of factors contributing to change. We will also collect information on treatment costs and other societal resource use, and conduct interviews with children, parents and stakeholders for information about scalability and acceptability.Plan for project realisation Treatments are shaped in collaborations between researchers, families and clinicians. Parents will be recruited from child and adolescent psychiatry, primary care and through advertisements. Treatments will be managed by clinicians. Costs are necessary for a large treatment study. Relevance The study is expected to lead to new knowledge about effects and cost effectiveness of low- and highly intensive interventions for parents and youth, scalability of a digital parenting program, experiences and usefulness of VR in CBT, factors related to treatment effectiveness and societal use of a stepwise model.

Children of incarcerated parents comprise a greatly disadvantaged group with high needs that are largelyoverlooked by society. These children run a greater risk for a number of health-related outcomes, and owndelinquency. Research suggests that these children need support that focus on their resilience. The non-incarceratedcaregiver is key here, but the caregiver may also be negatively affected by a partner’sincarceration and in need of support for the own well-being and to be able to support the child.Internationally, few support interventions for these children and caregivers have been evaluated scientifically. InSweden, current support is uncoordinated, largely unavailable, and provided by non-profit organisations. In fact,the responsible stakeholder, the Social Services, largely lacks knowledge about the children’s needs.Interventions to support child resilience in general focus on promotive factors of the child and context, whereparenting is emphasised.This project aims to develop and assess an evidence-based intervention that can be integratedinto existing Social Services to simultaneously support psychosocial health for the children ofincarcerated parents and their non-incarcerated caregivers.The project includes. 1. Development phase: Co-creation of intervention with stakeholders and users on importantfeatures of an intervention (study 1) and implementation in the Social services (study 2) are explored. Studies 1-2 together with results from systematic reviews which the applicant (ÅN) has been granted funding to conductduring 2021, will identify a suitable intervention. 2. Evaluation phase: feasibility and intervention effects onpsychosocial outcomes are teste in a randomised controlled trial (study 3) and mediated effects are explored(study 4).This project will provide the Social Services with an evidens-based method to decrease these chidlren´s suffering and prevent future ill health, delinquency and marginalisation of the children and their caregivers.