ECHO: Optimizing a group-based school intervention for children with emotional problems

Many children and adolescents struggle with anxiety and depression — including at levels that may not meet the criteria for a diagnosis, but still significantly affect everyday life. School-based interventions such as EMOTION Coping Kidshave shown positive effects and have the potential to reach large numbers of children at an early stage.

Knowledge gaps

• What are the effects and cost-effectiveness of digital health interventions for children and adolescents with mental health problems?
• What is the effect of feedback-informed services (feedback systems) for children and adolescents?
• What is the effect of school-based interventions aimed at preventing depression and/or anxiety in children and adolescents?
  

What did we still lack knowledge about?

• What actually makes these interventions most effective
• Whether digital solutions produce results comparable to traditional formats
• Whether feedback systems improve outcomes
• How much parental involvement is needed
• Which approaches provide the greatest impact per dollar spent

Where does the project fit in?

ECHO builds on previous research (the TIM study) and takes it one step further:
Not just whether interventions work — but how they can be made simpler, more cost-effective, and more accessible without losing effectiveness.

Executive Summary

ECHO explored how to optimise school-based interventions for children with symptoms of anxiety and depression for use in primary care and community services — with the goal of helping more children using limited resources.

A large number of school-aged children struggle with anxiety and depression, often at levels that do not qualify for specialist mental health services, but still affect learning, wellbeing, and development. Municipal and frontline services need interventions that are effective, feasible, and cost-efficient.

The project built on the EMOTION Coping Kids intervention and used a large cluster-randomised factorial design in Norwegian schools. Different combinations of intervention components — digital delivery, parental involvement, and feedback systems — were tested to identify the most effective and resource-efficient model.

All versions of the intervention led to reductions in children’s anxiety and depression symptoms. More complex and resource-intensive approaches did not produce better outcomes than the simplest versions.

The findings show that a simplified, low-threshold intervention can achieve results comparable to more comprehensive approaches. This creates opportunities for far more children to receive early support within the framework of frontline services.

Methodology

Design: Quantitative, cluster-randomised factorial study (MOST framework)

Sample: 58 schools in Norway, including children with clinical and subclinical symptoms of anxiety and depression

Data Collection: Electronic questionnaires, digital assessment tools, and longitudinal measurements

Analysis: Comparison of outcomes across eight experimental conditions

Limitations:

• Recruitment challenges and participant dropout during the Covid-19 pandemic
• A smaller sample size than planned reduced statistical power
• Variations in implementation quality across municipalities and schools

Results

Main Findings

• All intervention variants led to reductions in symptoms of anxiety and depression
• No additional components (digitalisation, increased parental involvement, or MFS/feedback systems) produced significantly better outcomes
• The least resource-intensive model was just as effective as the more complex approaches

Secondary Findings

• Simple, freely available assessment tools demonstrated good psychometric quality
• Parental involvement did not necessarily lead to greater symptom reduction
• Teachers’ assessments of children’s functioning were influenced by individual frames of reference
• Services require ongoing support to ensure sustainable implementation after the project period ends

Conclusion

ECHO demonstrates that it is possible to help more children with anxiety and depression without increasing the complexity of interventions. Simple, structured, and feasible interventions can have a substantial impact within frontline services.

The project challenges the assumption that “more is better” and provides a strong evidence base for prioritising interventions that are both effective and scalable.

What should researchers, practitioners, and policymakers take away from this?

• Prioritise interventions that can reach large numbers of children early
• Resource-intensive add-ons are not always necessary
• Schools are a key arena for mental health promotion
• Optimisation is as much about accessibility as it is about effectiveness

Further research

There is a need for follow-up studies examining long-term outcomes and implementation within routine services over time.