Evaluating the Back 2 School Program in a Norwegian Setting: A Multicenter Pilot Study
Phase: NA
Conditions: Absence, School Phobia, Truancy; Socialized, Depression, Anxiety
Sponsor: University of Tromso

 
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Research protocol: 
Evaluating the Back 2 school program in a Norwegian setting: A 
multicenter pilot study. 
Revised Version–  Date 21st October 2022  
 
Background 
Some youth find it difficult to attend school. This may lead to absence, intermittent or continued, 
which jeopardizes academic development (Carroll, 2010) and often contributes to impaired social-
emotional development (Malcolm, Wilson, Davidson, & Krik, 2003). Recurrent and prolonged school 
absenteeism is a complex problem with numerous causes (Havik et al., 2015) and risk factors (Ingul, 
Klöckner, Silverman, & Nordahl, 2012). It is also a major predictor for school drop-out (Calderon et 
al., 2009; Christle, Jolivette, & Nelson, 2007). Longer-term problems linked with school drop-out 
include unemployment, imprisonment, ill-health, and marital problems (Kearney, 2016). 
Problematic school absenteeism (SA) has been defined by Kearney (2008) as: (1) having missed at 
least 25% of total school time for at least 2 weeks, (2) experienced severe difficulty attending classes 
for at least 2 weeks, with a significant interference in the young person’s or family’s daily routines, 
or (3) had more than 10 days (or 15 %) absence during any 15-week period in the school year. In this 
study, the definition by Kearney (2008) for problematic absenteeism is adapted. One advantage of 
this definition is that it allows for interventions with youths whose absence is sporadic but still 
problematic.  
There has been considerable confusion on how to conceptualize School attendance problems (SAP). 
Terms such as truancy (TR) and school refusal (SR) have traditionally been used to describe different 
types of problematic school absenteeism (e.g Heyne, et al., 2019), and interventions have usually 
been designed for either TR or SR. Research indicate that groups overlap, and that diagnostic 
heterogeneity is considerable (Egger, Costello, & Angold, 2003).  
In Norway, there are no official guidelines and records for registering absence in primary and 
secondary education. Therefore, few reliable measures of the proportion of children and youth with 
SA in Norway exists (Palmu et al., 2021). One study of 5465 pupils in 6th to 10th grade showed that 
3,9 % had been absent for more than 10 days within the last 3 months, which qualify for SA, and 
7.5% of the students were absent more than 8 days last 3 months, which constitute 13.3% of the 
schooldays (or more) (Havik et al., 2015). According to descriptions of school and health 
professionals, the proportion of young people with problematic SA seem to have augmented during 
the Covid-19-pandemic.   
A recent meta-analysis of six psychosocial interventions for SR, five Cognitive Behavioural Treatment 
(CBT) trials and two medication plus CBT trials, showed a significant reduction in school absenteeism 
with a moderate effect size (g = .54), but no significant effects on anxiety symptoms (B. Maynard et 
al., 2018). A systematic review of TR interventions found a moderate and significant mean effect-
size, g = .46 (average improvement in attendance of 4.69 days), but 15 of the 16 studies reported 
absence rates above 10% posttreatment (B. R. Maynard, McCrea, K. T., Pigott, T. D., Kelly, M. S., 
2013) .  
Researchers have called for an integrated and common perspective to the complex problem of 
school absenteeism, that take into consideration the multiple causes and risk factors, and both 

 
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personal, familial and school related factors that influence the individual youth (Kearney & Albano, 
2004). There is a need for studies that develop and evaluate integrated and comprehensive 
interventions to problematic SA, which incorporate different treatment needs of this heterogeneous 
group (Kearney & Ross, 2014; Maynard et al., 2013). Few such studies exist, with one exception 
being the Back2School (B2S) study in Aarhus, Denmark (Thastum et al., 2019). The Back2School (B2S) 
program is a modular trans-diagnostic CBT intervention aimed at increasing school attendance and 
decreasing psychological problems among youths with problematic SA. The Danish B2S study was a 
randomized controlled treatment trial comparing the effects of the B2S program against treatment 
as usual (N= 152; 60.5 % boys; 12.15 years mean age) (Lomholt et al., 2020; Thastum et al., 2019). 
Results of the B2S study, indicated significant and positive effects on attendance rate from pre to 3-
month follow-up (d = 0.73) for the B2S condition, but with no significant difference when compared 
to the TAU condition (d = 0.60) (Johnsen, Lomholt, Heyne, Jensen, Jeppesen, Silverman, & Thastum, 
2020). The B2S study in Denmark faced challenges with the validity of measurements of school 
attendance and found insufficient correspondence between parental reports on absence data with 
official records data. This made the interpretation of results difficult. The B2S study found, however, 
that the youths in the B2S group had significantly larger reductions in symptoms of psychological 
problems (e.g., the Strengths and Difficulty Questionnaires) and improvement in school related self-
efficacy from pre – 3-month follow-up compared to youths receiving TAU, with on average medium 
group effect sizes (d’s ranging from .29 to .58). 
The theoretical approach of the B2S program is transdiagnostical, based on a modular CBT manual. 
The program aims at addressing both school attendance problems and mental health problems that 
are associated with SA. The intervention combines a functional and a CBT approach. The functional 
approach involves identifying the motivational function of the child’s school absenteeism and 
includes 1) avoidance of school-based situations that provoke negative affectivity 
(anxiety/depression), 2) avoidance of aversive school-based social/evaluative situations, 3) pursuit of 
attention from significant others outside of school, and 4) pursuit of tangible reinforcement outside 
of school. The cognitive approach addresses prevalent negative cognitions in this group, e.g., 
cognitions concerning the youth’s ability to cope with situations related to school attendance 
(Thastum et al., 2019). Also, focus on increasing school related self-efficacy may reduce associated 
emotional and behavioural problems and promote reengagement with school. 
 
Scope of the research project 
Pilot study: 
In Norway, there is a lack of a clear and systematic approach for helping children and youths with 
problematic SA. Developing effective interventions and procedures for helping children with SA is 
important. The ambition of the present study is to adapt a new and promising intervention, aiming 
to improve the help offered to children, youth and families struggling with problematic SA in 
Norway.  
The Norwegian B2S study is developed in collaboration with Professor Mikael Thastum at the 
University of Aarhus, Denmark. The planned pilot study is a collaboration between researchers at all 
the four Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU North, West, 
Middle and RBUP South/East), and at the University of Bergen, Stavanger, Norwegian University of 
Science and Technology (NTNU), UiT the Arctic University of Norway, and the University of Aarhus, 
Denmark.  

 
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In the pilot study, the B2S program will be tested and evaluated in eight municipalities in all regions 
in Norway. Data will be collected during the school term of 2022-23. Based on the experiences from 
the pilot study, the research group aims to develop a large-scale randomized control intervention 
study of B2S in Norway. 
 
Primary aims 
The pilot has several aims. One overall aim is to gain experience in using the Back 2 School 
program in Norwegian community school- and health services and to assess the feasibility of the 
program in those settings. Another aim is to prepare and establish resources and infrastructure for a 
larger intervention study, and to establish a well-functioning cooperation between researchers, 
research organizations, and municipalities in different regions. Also, questions regarding the process 
of implementation of the program in community service settings will be an important issue for the 
pilot study.  
By using a mixed method approach we will combine quantitative and qualitative methods 
addressing the following research questions:  
Quantitative:  
1. What are the characteristics of youths with SA and their families? 
2. What are the changes in school absence rate, school related self-efficacy, and 
psychological difficulties following the intervention?  
3. What additional needs for interventions and services are identified at termination of 
the program?  
4. What is the degree of drop out, and level of satisfaction with the B2S program 
among children, parents and teachers? 
Qualitative: 
5. How do children, youths and their caregivers experience the B2S program? In what 
ways has the intervention been helpful? Are there ways the program and service 
system should be changed to better fit the needs of the youth and families 
struggling with SA? What would be optimized treatment and services for this group?  
6. How do the therapists experience working with the B2S program to help children 
and youth with problematic SA? How did the therapists experience the training, the 
manual and the supervision? Are there ways the program and service system should 
be changed to better fit the needs of the youngster and families struggling with SA? 
What do the therapists consider to be optimized treatment and services for this 
group? 
7. How do school staff experience the B2S program and the extended school module?  
Based on the findings from the pilot study we aim to answer the following questions:  
• 
How should a larger-scale implementations study of the Back 2 School program be planned, 
optimized and conducted?  
• 
What should be the treatment comparison condition? 
• 
What is an optimal level of school involvement in B2S? 
 
 
 

 
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Resources and timeline 
Figure 1: Timeline of the pilot study in Norway 
 
 
Project period 
Data for the pilot project will be collected during the schoolyear of 2022 -2023. The analysis of the 
results and writing of reports are planned for the autumn of 2023. During the same time the project 
group plans to write the application for funding of the national effectiveness and implementation 
study, the main study.  
The training of the professionals teams in the B2S program will be given during the week from the 
21st to the 25th of March 2022. Beforehand, the teams have recruited a case for the first 
implementation of the program (the rehearsal case). The project group recommends that the first 
implementation is conducted shortly after the week of training. The data collected during the 
rehearsal case will not be included in the database of the pilot. The teams will meet with the 
supervisor team weekly as soon as they start implementing the B2S.  
From august 2022 through June 2023 each team will conduct the B2S program and collect data from 
two cases each.  
 
Methods:  
Participants and settings:  
16 youth (6-16 years of age) will be included in the pilot study. The study will be conducted in eight 
Norwegian municipalities. Each region (East, West, Middle, North) recruits one to two teams of 
professionals from their geographical area. The setting for the B2S intervention is within first line 
services in the municipalities that are imposed to provide services for the target group.  
Inclusion/ exclusion 
In the pilot study, the following inclusion criteria applies:  
1) Youth enrolled in a public school within the municipality,  
2) aged 6–16 years and in 1st to -10th grade (excluding second semester of the 10th grade), 

 
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3) having a level of school absenteeism above 10% during the last 3 months of school (excluding 
legal absence, e.g., permitted extra holidays),  
4) The youth and at least one parent/caregiver understand and speak Norwegian sufficiently to 
participate in the intervention and complete questionnaires,  
5) At minimum one of the parents is motivated for working on increasing the youth’s school 
attendance,  
6) The participating families are willing to record baseline levels of school absenteeism and to 
participate in assessment, intervention procedures, and follow-up assessment,  
7) Written informed consent from caregiver with judicial parental rights and responsibilities (usually 
both parents) to take part in the B2S pilot study is obtained.  
8) Youth with a diagnosis of autism spectrum disorders cannot be included in the pilot study 
(exclusion criteria). Also, youth in need of acute and/or more intensive specialist mental health 
services (e.g., due to suicidal risk, ongoing symptoms of psychosis, ongoing eating disorder) cannot 
be included.  
 
Design:  
Quantitative study: 
The evaluation of changes in school absenteeism (primary outcome) of the B2S program will be 
conducted using a multiple - baseline across subjects’ design comparing the individuals’ baseline 
levels of school absenteeism with the level of absenteeism following participation in the B2S 
program. The structure of the multiple baseline design with 16 subjects is comprised of two 
treatment conditions, a baseline (control) and an intervention condition with N equally spaced 
measurement occasions (Hedges, Pustejovsky, & Shadish, 2013). Thus, each subject function as their 
own control. Changes in secondary outcome measures (psychological wellbeing, school related self-
efficacy) are assessed through repeated measurement at pre- (T1), and post intervention (T2). 
Information regarding additional needs for interventions and services is registered at T2 and at the 
3-month booster session (T3). 
 
Qualitative study:  
In-depth interviews with 8-10 of the young people, their caregivers and school personnel concerning 
their experience with participating in the B2S program will be conducted. The interviews will explore 
questions concerning program specific evaluation, but also questions to identify important success 
criteria and obstacles to getting help from the intervention. Focus group interviews with 
professionals concerning feasibility of the B2S program within the system of care will be conducted. 
 
Procedure:  
Professionals 
Each municipality forms a B2S Team consisting of three professionals. The teams will be 
interdisciplinary including both member(s) with a relevant health profession (clinical psychologist, 
medical doctor, health nurse, social educator) and member(s) within a pedagogical profession 
(teacher, special educator). 

 
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Training 
All professionals receive a 5-days training course comprising assessment measures and proceedings, 
case formulation and the Back 2 School manual. Following training, the teams will be given weekly 
supervision by an interdisciplinary team of supervisors, consisting of 1 CBT expert and one with 
educational professional background, to ensure adherence and quality in delivery. The B2S teams 
receive a total of 70 hours of training (35 hours) and supervision (estimated 35 hours) during the 
pilot study.  
Recruitment 
The recruitment procedure for the Back2School pilot study is as follows:  
1. The Back 2 School team in the communal service go through referrals to find students that 
can be relevant for inclusion to the pilot project.  
2. Administrative personnel from the communal service send out information about the pilot 
students to relevant youths and families, together with other information concerning their 
referral to the service. In the information-brochure the contact information for setting up an 
information meeting about the B2S pilot project is provided. The families are encouraged to 
contact the service to set up an information meeting within a week from the time when they 
received the information.   
3. If the family haven´t contacted the service within 10 days, they will be assigned the 
communal service´s ordinary measures.    
4. When the family contact the communal service to schedule an information meeting the 
service find a time and place for the meeting with the family. Information regarding the 
project and consent is not presented on the telephone.   
5. In the information meeting with the family the B2S team from the communal service present 
the B2S program, and the procedures for the pilot project.  
6. The family get the “Informed consent to participate in the B2S – pilot study" (“Samtykkeskriv 
for deltakelse i B2S-pilotstudie”) and are asked to contact the service within a week if they 
wish to consent to participate in the project.  
7. When the informed consent is signed the student and caregivers receive the collection of 
questionnaires (T1) on paper, together with scheme for registering school absence to the 
youth and to the parents.   
8. When the T1-qestionnaires from the youth and both parents are returned to the B2S team 
they are archived in the communal service secure journal system.  
9. The parents sign the communal service consent scheme to allow cooperation with the 
school. 
10. When the consent to contact/cooperate with the school is signed, the B2S team contact the 
school to inform about the B2S, and to hand out the T1 questionnaire to the main teacher. 
11. The B2S-teams of the communal services collect the questionnaires, and the person-
identifiable information is removed (name and date of birth are removed). The 
questionnaires are sent to the local project coordinator for that region. To calculate scores 
according to standardized norms information regarding gender and age must be provided 
for each individual.    
Assessment 
All data collection and assessment within the pilot study are obtained for two main aims: 1) To 
inform treatment planning and adjustment of the intervention when implementing the B2S program 
with each individual youth and family, and 2) To answer the research questions of the pilot study.  

 
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At inclusion to the pilot study, the youth, parents and teachers immediately start to register school 
absence (primary outcome) daily on paper form. The Back2School team send the T1 collection of 
questionnaires on paper forms to the families by post or the questionnaires are handed to the 
families when they sign the informed consent to participate in the pilot study. Youth aged ≤ 11 years 
fill out the questionnaire themselves. Children aged ≥ 10 years fill out the questionnaire with the aid 
from the B2S counsellor/team. The absence registration forms and the collection of questionnaires 
at T1 from the youth and the parents are collected by the B2S team at the pre-meeting interviews. 
Collection of T1 questionnaires from the school is sent by post and collected by the B2S team at the 
first school meeting. Two weeks prior to the last meeting (T2), the collection of T2 questionnaires is 
sent in paper form to the youth, the parents and the school. T2 assessments are collected by the B2S 
team at the last session of the program (T2). Assessment from the school is collected by the B2S 
team at the last school meeting (T2) or at the booster session with the school. The paper forms from 
the T1 and T2 assessments are handed over to the regional project manager in the next supervision 
session after the data has been collected from the families and schools.  
 
Measures:  
Primary outcome measures 
The primary outcome measure is school absence data registered on paper-form on a daily basis by 
teachers, parents’ and youths 2 weeks prior to initiation of the program (T1), 2 weeks prior to the 
finalization of the program (T2) and 2 weeks prior to the 3-month follow-up meetings (T3). We use a 
revised version of the absence register form included in the Back 2 School manual (see appendix 1). 
The informants register presence/absence session by session during their school day, including a 
remark on presence according to their individual schedule. The forms from all informants are 
handed in to the B2S counsellor.  
Informants start recording absence data for the baseline phase immediately after signing the 
informed consent. Absence data will be recorded in days and hours absent from school. In addition, 
official school record absence data is recorded retrospectively during a period of 2 weeks prior to 
initiation of the program (T1), 2 weeks prior to the finalization of the program (T2) and 2 weeks prior 
to the 3-month follow-up meetings (T3).  
Secondary outcome measures: 
Secondary outcomes measure changes in psychological wellbeing, quality of life, and issues related 
to difficulties attending school. Secondary measures are repeated at baseline and at termination of 
the program (T2). 
The Strengths and Difficulties Questionnaire (SDQ-C/P/T): The SDQ (Goodman, 1997) is a 25- item 
screening instrument covering emotional, behavioural and social difficulties, peer relations, prosocial 
behavior, as well as five questions regarding functional impairment in children and adolescents (2 – 
17 years of age). Both the self-report version (from age 11), and the parent- and teacher- report 
versions will be used. The SDQ is a well-established and widely used measure with acceptable to 
good psychometric properties (Goodman, 2001; H. Kornør & Heyerdahl, 2013; H. Heyerdahl Kornør, 
S., 2014; H. & Heyerdahl Kornør, S., 2017) 
The Spence Children’s Anxiety Scale (SCAS C/P) (Spence, 1998): The SCAS is a self-report and parent 
reported rating scale with 38 items (child version includes additional six positive filler items) regarding 
symptoms of anxiety rated on a 4-point scale. SCAS consists of six subscales: social phobia (six items), 
panic disorder and agoraphobia (nine items), generalized anxiety disorder (six items), obsessive–

 
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compulsive disorder (six items), separation anxiety disorder (six items), and fear of physical injury 
/simple phobia (five items). Both the youth (SCAS-C) and the parent version (SCAS-P) will be used. 
SCAS has demonstrated good psychometric properties internationally as well as in previous 
Scandinavian intervention studies (Arendt, Hougaard, & Thastum, 2014; Haugland et al., 2020; Nauta 
et al., 2004; Wergeland et. al, 2014).  
The Mood and Feelings Questionnaire (MFQ C/P) (Angold et al., 1995; Costello & Angold, 1988): The 
MFQ is a 33-item screening tool for depression in youths aged 6 to 19 years. In the pilot study we use 
the short version of the MFQ with 13 items. The MFQ includes a youth (MFQ-C) and a parent version 
(MFQ-P). The MFQ is valid in identifying children presenting with major depressive episodes, and the 
MFQ-C and the MFQ-P used in combination augment this validity (Daviss et al., 2006). The Norwegian 
version of the MFQ has shown good psychometric properties (Richter, 2013).  
The Self-efficacy Questionnaire for School Situations (SEQ-SS) (Heyne, 1998) was developed to assess 
the expectations of school-refusing youth concerning self-efficacy. The SEQ-SS consists of 12 items, 
and 2 sub-scales: Academic/Social Stress and Separation/Discipline Stress. Evaluation of the SEQ-SS 
has shown good psychometric properties (Heyne et al., 1998). The SEQ-SS is being translated into 
Norwegian by the research group as part of the pilot study.  
The Self-efficacy Questionnaire Responding to School Attendance Problems (SEQ-RSAP) (Heyne, Maric, 
& Westenberg, 2007) was developed to assess parents' self-efficacy regarding helping their child to 
attend school regularly and without difficulty (Heyne et al., 2007). The psychometric properties of the 
SEQ-RSAP have in a preliminary study showed promising convergent validity and good temporal 
stability (Lavooi, 2010). The SEQ- RSAP is being translated into Norwegian by the research group as 
part of the pilot study. 
Om å bli mobbet (Olweus, 1992): The youths' personal experience of being bullied. Bullying will be 
defined as “a student is being bullied when he or she is exposed repeatedly over time to 
negative and hurtful actions on the part of one or more students. It is difficult for the student 
being bullied to defend himself or herself. Bullying may take place frequently or infrequently. 
Bullying can be verbal (e.g., name-calling, threats), physical (e.g., hitting) or psychological (e.g., 
rumors, shunning/exclusion). It is bullying when someone is teasing repeatedly in a mean or 
hurtful way” (Olweus, 1993). 
School Refusal Assessment Scale-Revised - Child (SRAS-R) (Kearney, 2006) was designed to evaluate 
the relative strength of four functional conditions of school refusal in youths; (1) avoid stimuli that 
provoke negative affectivity, (2) escape aversive social and/or evaluative situations, (3) pursue 
attention from significant others, and/or (4) pursue tangible re-enforcers outside of school. The 
SRAS-R-C consists of a child and parent version. The scale indicates the strength of the four 
functional conditions of school refusal in youths’ and is rated by both youth and parent. The SRAS-R 
has been translated into Norwegian by Trude Havik, Jo Magne Ingul and Arne Kodal.  
The Family Assessment Device (FAD) (Epstein, Baldwin, & Bishop, 1983) was developed to assess 
dimensions of family function. It consists of three subscales, with 60 statements describing various 
aspects of family functioning. FAD is designed to be completed by family members over the age of 12 
years and has been evaluated as a good measure of the overall family functioning, with excellent 
psychometric properties (Epstein et al., 1983; Miller, Ryan, Keitner, Bishop, & Epstein, 2000). The 
translation into Norwegian was done by professor Anne Mari Sund (NTNU). In the pilot study we use 
the general functioning scale with 12 items. This short version has been utilized independently in 
Norwegian studies.  

 
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KIDSCREEN-27 (Ravens-Sieberer, 2006) is a 27-item scale used to assess generic health-related quality 
of life. The KIDSCREEN comes in a child version and a parent proxy-version. The scale has five 
dimensions: Physical Well-Being, Psychological Well-Being, Autonomy & Parents, Peers & Social 
Support and School Environment. Internal consistency values (Cronbach's Alpha) range between .79 
(Physical Well-being) and .84 (Psychological Well-being) for the different dimensions for the self-
report versions. Item intraclass correlation (ICC) between self-reported scores and scores from 
parents filling out the KIDSCREEN-27 proxy-version ranging from 0.44 (Social Support & Peers) and .61 
(Physical Well-Being) (Haraldstad & Richter, 2014). In Norway a study (Andersen et al., 2016) has 
documented good reliability and validity. 
Other measures: 
Background information: Participating families will complete a background information 
questionnaire regarding family demographics, youth’s school and SA problems, and youth’s previous 
and ongoing treatment. Information regarding the experience of collaboration between the family 
and the school will be collected from both parents and teachers. Socio-economic data related to 
various background characteristics about children and parents will also be recorded from the parents. 
Evaluation of the service: The Norwegian version of the Experience of Service Questionnaire (ESQ) is 
used at postintervention (T2) to assess youth and parent satisfaction with the B2S intervention 
(Attride-Stirling, 2002). Separate versions of the ESQ will be administered to youth and parents (both 
12 items), including open questions for qualitative feedback.  
 
 

 
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In Table 1, an overview of measures, respondents and assessment points are presented.   
 Table 2: Overview of measures, respondents, and assessment point 
Measures 
 
Respondent 
Time 
Primary outcome measure: 
 
T1 
T2 
T3 
School absence – youth reported 
Y 
X 
X 
X 
School absence - parent-reported 
P 
X 
X 
X 
School absence - teacher-reported 
T 
X 
X 
X 
Secondary outcome measures: 
 
 
 
 
SDQ  
 
Y, P, T 
X 
X 
 
About bullying 
 
Y 
X 
X 
 
FAD 
 
Y, P 
X 
X 
 
SCAS 
 
Y, P 
X 
X 
 
SMFQ 
 
Y, P 
X 
X 
 
Kid screen 
 
Y, P 
X 
X 
 
SEQ-SS  
 
Y 
X 
X 
 
SEQ-RSAP  
 
P 
X 
X 
 
Other measures: 
 
 
 
 
Background information 
P, T 
X 
 
 
School and family collaboration 
P, T 
X 
X 
 
SRAS-R 
Y, P 
X 
 
 
ESQ 
Y, P 
 
X 
 
 
The intervention and its delivery 
Content 
We will use the Danish version of the revised manual developed within the B2S study in Aarhus. The 
B2S program consists of a 3 to 3,5 -hour initial clinical assessment, a clinical conference, 11 sessions 
where the youth and/or parent are attending, and a booster session after three months including 
youth and parent. The B2S manual comprise four school meetings with the child, parents, school 
staff and therapists present. In the Norwegian pilot study, we will add an extended school module to 
the B2S-program which is further described below. In Figure 1, the outline of the program is 
presented.  

 
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Table 1: Overview of the Back2School program 
Week 
Session 
Duration 
(hours) 
Module 
Participant 
Session content 
1 
Pre-meeting 
interviews 
3-3,5  
All 
Y, P, T 
Anamnestic information, information about the child’s schooling, somatic complaints, motivational 
assessment, introduction to SMART-goals, psychopathological interview.  
2 
1 
1 
All 
Y, P, T 
Caseformulation, psychoeducation absenteeism, establish SMART-goals, introduction to rewards.  
 
2 
1,5 
All 
P, T 
Establish good routines, introduction to praise and rewards 
3 
3 
1 
All 
P, T 
Encourage positive behaviors in the child, promote clear and friendly requests, ignore undesirable 
behaviors.   
 
4 
1 
All 
Y, P, T 
The impact of avoidance behavior, psychoeducation about exposure, plan the graduated exposure-plan 
for returning to school, plan first school meeting.    
4 
School-meeting 1 
 
 
 
5 
5 
1 
All 
Y, P, T 
Psychoeducation about cognitive-diamant, cognitive restructuring, and the childs main difficulty. 
Continue to work with graduated exposure plan for school absence.  
6 
6 
1 
All 
Y, P, T 
Follow-up on realistic thinking, on the school-presence ladder, and going to school.  Problemsolving 
 
 
 
All 
P, T 
Parent support during exposure, positive moments with youth 
7 
7 
1 
Anxiety  
Y, P, T 
Safety behavior, stepladder approach to fears.  
 
 
 
Depression 
Y, P, T 
Depression vicious cycle, activity plan, pleasant activity planning, positive diary.  
 
 
 
Conduct 
P, T 
Family rules work with a token-reward system. 
 
School-meeting 2 
 
 
 
8 
8 
 
 
 
Parent behavior 
 
 
1 
Anxiety  
P, T 
Parenting anxious children, alternative parenting behaviors, foster independence and brave behavior. 
 
 
1 
Depression 
P, T 
Psychoeducation about depression in youth, parent support of behavioral activation 
 
 
1 
Conduct 
P, T 
Introduction to negative consequences for negative behavior 
 
 
 
 
 
 
9 
9 
1 
Anxiety  
Y, P, T 
Exposure – plan and perform. 
 
 
1 
Depression 
Y, P, T 
Behavioral activation – discussion 
 
 
1 
Conduct 
P, T 
Prepare Family meeting with problem solving 
10 
10 
1 
All  
Optional 
Optional theme 
12 
11 
1 
All 
Y, P, T 
Proceed with the progress, identify success, what should be continued, prevent relapse, evaluation of 
treatment 
13 
School-meeting 3 
 
 
 
3-
months 
Booster-session 
 
 
Evaluation of continued progress, problem solving, further needs of service 
 
School-meeting 4 
 
 
 

 
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Clinical interview and case formulation 
The intervention starts with the families attending a 3-3.5-hour clinical interview that consists of a 
range of structured questions. The interview aims to achieve an understanding of the youngster’s 
school absenteeism, development, the family and social situation, and functioning in daily life. The 
interview also includes a structured joint youth and parent interview developed for the B2S program 
to assess type and degree of potential mental health problems in the youth. 
Following the initial assessment, a case-formulation according to Carr (2015) is developed in 
cooperation between the B2S counsellor/team and family. The case formulation is based on the 
qualitative and quantitative information from the interviews and the baseline measures. The family 
and the B2S counsellor/team identify the motivational function of the child’s school absenteeism, 
which decides which module in the program that will best fit the individual youth and his/her family. 
When school absenteeism is identified as motivated by positive reinforcement, CBT procedures 
targeting parent management and contingency management to minimize the incentives for 
absenteeism and augment incentives for attendance are indicated. School absenteeism identified as 
motivated by negative reinforcement involves CBT procedures such as cognitive restructuring, and 
exposure-based interventions to reduce anxious or depressive symptoms. The manual includes and 
targets both specific SAP related tasks, and symptom-specific modules targeting subclinical or clinical 
levels of anxiety, depression, or behavioural problems. During the first two weeks of the 
intervention, there are two weekly sessions to emphasize the importance of immediately increasing 
school attendance. The following 6 sessions include weekly or biweekly sessions as appropriate for 
each family. The conducting of the booster session is flexible regarding the timing and will be held 
within 3 months after the last session.  
At termination of the B2S program, an evaluation of outcomes and further needs for interventions 
will be discussed with the families. Youths with unchanged or worsened absenteeism following the 
intervention, and youths with clinical levels of anxiety, depression, or behavioural disturbance will 
be referred for further treatment. Registration of what additional interventions or other services 
that are attended is recorded at T2 as well as at follow- up (T3).  
Drop-out: In case of treatment dropout, both youths and parents will receive the SDQ and 
ESQ questionnaires. Teachers also receive the SDQ, and the ESQ if the dropout occurs after the first 
school meeting. The primary measure of school absence will be available for all participants, 
regardless of dropout. In case of drop-out, the therapist team recruit a new case in case of drop-out 
to maintain the goal of two completed cases for each team. 
The school module: Collaborating with the school is important in the B2S and four meetings 
with teachers from the youth’s school, the B2S counsellor/team, and parents and also a booster 
session 3 months after the program are included in the manual. We will add a school module 
developed for the pilot to include the schools from the beginning of the program to facilitate a 
positive school environment for the child and collaboration between the school and the family. The 
school module includes a pre-meeting interview with the schools in week 1 and session 1 with the 
school in week 2 or 3. These are in addition to the sessions described in Table 1. The 
counsellor/team and the school will decide whether there is a need for an additional meeting 
between school meetings 1 and 2.  
 

 
13 
 
 
Study organization 
Main research group 
UIT The Arctic University of Norway 
 
Institutt for psykologi  
Toril Sørheim Nilsen 
Toril Sørheim Nilsen an associated professor in clinical psychology and is a specialist in clinical child 
and adolescent psychology. Nilsen did her Phd based on data from a naturalistic observational study 
in Child and Adolescent Mental health services focusing on change during treatment for children and 
adolescents with anxiety and/or depressive disorders. She has several years of clinical experience in 
working with youth and families that struggle with SA. She is a trained CBT therapist and have 
experience as a CBT supervisor.   
RKBU Nord 
 
 
Henriette Kyrrestad 
Henriette Kyrrestad is an associate professor at Regional Centre for Child and Youth Mental Health 
and Child Welfare – North (RKBU North) at UiT the Arctic University of Norway. She has a PhD in 
Health Science and a master’s degree in psychology. She has experience with effect evaluations and 
serve as PI for two RCT studies among adolescents. 
RKBU Nord 
 
 
Frode Adolfsen 
Frode Adolfsen is a assiciate professor at Regional Centre for Child and Youth Mental Health and 
Child Welfare – North (RKBU North) at UiT the Arctic University of Norway. He has a PhD in Health 
science and master’s degree in special education. He has experience as regional PI in the TIM and 
ECHO studies focusing an anxiety, depression and implementation factors in school settings.  
RKBU Nord 
 
 
Marte Rye 
Marte Rye is an associate professor at the Regional Centre for Child and Youth Mental Health and 
Child Welfare – North (RKBU North), at UiT The Arctic University of Norway. She has a PhD in Health 
Science and is a clinical psychologist with a specialist degree in work with adults. She has experience 
participating in RCT studies, as well as several years' experience with clinical work and supervision.  
NTNU 
 
RKBU Midt 
 
 
Jo Magne Ingul 
Jo Magne Ingul has been doing research on SAP for many years. He has also led an RCT for 
adolescent Social Phobia in Norway and is currently the regional PI for the ECHO study. Jo Magne is a 
trained CBT-therapist and has worked clinically with SAP youth for 20 years.  
 
RBUP South/East 
 
 
Simon Peter Neumer 
Simon-Peter Neumer is a senior researcher at the Centre for Child and Adolescent Mental Health, 
Eastern and Southern Norway. He has conducted several RCT studies and is a clinical psychologist 
with a specialist degree and expert in the use of CBT programs.  
UIB 
 
Psykologisk fakultet 
 
Bente Storm Mowatt Haugland 

 
14 
 
Bente Storm Mowatt Haugland is a specialist in clinical psychology and is associated professor in 
clinical psychology. She is/has been participating as a researcher in four RCT studies, in addition to 
several open trials. She has been PI of a large study in school health services on indicated prevention 
for youth with anxiety. She is a trained CBT therapist, primarily working with internalizing problems 
in youth. 
NORCE 
 
RKBU Vest 
 
 
Kristin Gärtner Askeland 
Kristin Gärtner Askeland is a psychologist and senior researcher at the Regional Centre for Child and 
Adolescent Mental Health and Child Welfare (RKBU), NORCE. Her research interests centre on the 
understanding of mental health problems and resilience in high-risk groups, and the link with SA and 
dropout.  
UIS 
 
Læringsmiljøsenteret 
 
Trude Havik 
Trude Havik is an associate professor in educational psychology at the Norwegian Centre for 
Learning Environment and Behavioral Research in Education, University of Stavanger. Her PhD in 
special education was a study of the role of school factors in school refusal and school non-
attendance. Other research fields: classroom interactions, student engagement and peer relations.  
 
Universitetet i Aarhus  
 
Mikael Thastum 
Thastum is project manager of the B2S study at the University of Aarhus and Head of the Centre for 
Psychological Treatment for Children and Adolescents (CEBU). Thastum have extensive experience 
and expertise in conducting research on treatment development and efficacy trials. 
 
This is a research group with extended experience in running Randomized controlled trials in 
Norway. Professor Thastum is the author of B2S and has led the implementation and trial of the 
manual in Denmark. The research group has expert knowledge on SAP and many of the participants 
have studied the problem in multiple settings. The PI’s will be the management of the study (see 
below); overseeing data collection, training and supervision, implementation and budget issues. 
Each region will form their own organization and be responsible for carrying out the daily 
administration described in the protocol and decided by the management.  
National PI 
Toril Sørheim Nilsen and Jo Magne Ingul 
Regional PI 
North: Frode Adolfsen 
West: Kristin G Askeland 
East/South: Simon P Neumer 
Middle: Jo Magne Ingul 

 
15 
 
 
User representatives 
User involvement is important for the evaluation of the B2S intervention. Two parents having 
experience with SAP have been recruited as participants in the study group. They are both members 
of ADHD Norge. They will take part in meetings, workshops and in piloting instruments, interviews 
and in discussing new elements of the intervention.  
 
Plan for data management 
All data in the pilot study is collected on paper by the B2S therapists, who hand the questionnaires 
to the regional project manager. The paper forms are marked with each participant`s corresponding 
id-number, and personal identifiable information is removed from the paper forms. The anonymized 
collection of paper forms (copies) from all informants at T1, T2 and T3 is sent by post to the national 
project manager and the data from the questionnaires are registered into the datafile of the pilot 
project. The data will be managed according to UiT The Arctic University of Norway’s` principles and 
guidelines for research data management. Person identifiable information and the research data will 
be stored in separate files. An id-number will be the connection key between files. The PI is in 
contact with services at UiT to get guidance to ensure that the data will stored and processed 
continuously in a secure manner in accordance with the Management System for Information 
Security at UiT.  
Ethical consideration:  
Research on child and adolescent patients is one of the fields that require the most careful 
reflections on ethical issues. The study will be conducted in accordance with prevailing ethical 
standards, and approval from the Regional Ethic Committee (REK) and the Norwegian Centre for 
Research Data (NSD). The project will be run in line with The World Medical Association (WMA) 
Declaration of Helsinki. Before entering the pilot study, the families will receive oral and written 
information and sign an informed consent. The families will be informed that the participation in 
research is voluntary and that they can withdraw their consent at any point in time.  
Families that do not consent to participate in the pilot study will be offered help from the same first 
line services, without delay, but will not be offered the B2S program. Families who consent to 
participate but want to withdraw from the data collection after the intervention is started will be 
offered to continue with the B2S program. Whenever children and youths are identified as in need 
of extended interventions after the B2S program, the project will provide help with necessary 
referrals and guiding. 
Utility-risk assessments: Youths and families that are being asked to participate in the pilot study are 
all self-referred to first-line services within their municipality. They are selected from the referral list 
of the services and B2S is offered as one alternative to service as usual. The B2S program is a 
systematic and focused intervention involving both youths, parents/caregivers, and the school. 
Results from the Danish study showed that youths and caregivers involved in the B2S program 
reported more satisfaction with the service than youth and families receiving “treatment as usual”. 
One risk of participating the B2S program is that it is an intensive intervention requiring motivation 
and effort over time from youth, caregivers, and the school. Some participants may find the B2S 
programme too demanding or may develop a need for other interventions (eg. Suicidality). In such 
instances, the team of professionals providing the service, and the project group, is responsible for 
helping them with referrals and guiding.   

 
16 
 
The proposed study is a preparation of a large-scale intervention study in Norway, aimed at 
optimizing services for youths and families that struggle with SA. Together with the B2S study in 
Denmark, these studies may provide clinically relevant and useful information regarding how an 
integrated and systematic approach for helping children and youths with problematic SA is working 
within the system of care. Also, knowledge regarding which adjustments and improvements are 
needed both for the B2S program, but also for the system of care in order to improve outcomes, 
may prove valuable. A multi-informant perspective, along with the use of both quantitative and 
qualitative methods, may give valuable insight into how psychosocial treatments for SA ought to be 
tailored to fit the treatment needs of this heterogeneous group.  
 
Financing and conflicts of interest 
The pilot study has no external funding, but costs are shared between the research institutions 
involved in the study. The researchers involved in the project contribute to the project as part of 
their position at the research institution. The research group declare no conflict of interest.   
  
Measures for communication 
Communication with study participants about findings and knowledge gained from the study will be 
prioritized throughout the project. Dissemination of results of the research will be presented in 
national and international research- and clinic conferences, in public media and in level 1 and 2 peer 
reviewed journals. One article is planned from the study summarizing the main findings, but there is 
potential for several publications in peer reviewed journals. The study group will follow the 
Vancouver rules for publication. Open access publication will have a high priority. The goal of the 
pilot project is to write an application for research grants for a large-scale intervention study in 
Norway. 
 
 

 
17 
 
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