The case for intervention: Evaluation of programmes targeting anxiety

Symptoms of anxiety are distressing, associated with poorer school performance and social functioning (La Greca & Landoll, 2011; Wood, 2006), predictive of later psychological disorders (as described in the previous section), and costly to society (Snell et al., 2013). It is not surprising therefore that efforts have been made to develop programmes targeting anxiety in childhood. These interventions include

‘universal’ interventions, which are administered to a whole group regardless of levels of symptoms, and targeted interventions, aimed at children ‘at risk’ of developing an anxiety disorder, perhaps because their parent has been diagnosed with one (e.g. Ginsburg, 2009) or because they are already displaying high levels of anxiety symptoms (Dadds et al., 1999; Dadds et al., 1997).

One of the most widely used programmes targeting childhood anxiety is the

FRIENDS program (Barrett, Lowry-Webster, & Turner, 2000; Barrett, Sonderegger, &

Sonderegger, 2001; Barrett & Turner, 2001), a universal school-based intervention based on the principles of cognitive-behavioural therapy. The programme

originated from the Coping Koala program (Barrett, Dadds, & Rapee, 1996), an Australian version of the Coping Cat program (Kendall, 1990, 1994). It involves ten weekly sessions and two booster sessions between four and twelve weeks after the final session. The sessions teach skills in relaxation, cognitive restructuring, positive self-talk, parent assisted exposure and rewards. The programme has been shown to reduce symptoms of anxiety (Barrett and Turner, 2001) with group differences remaining at 12-month follow up (Webster, Barrett, & Dadds, 2001; Lowry-Webster, Barrett, & Lock, 2003). An additional study found that for 10-11 year old children (but not 13-14 year old children) intervention reductions in anxiety were maintained up to three years later (Barrett, Farrell, Ollendick, & Dadds, 2006; Lock

46

& Barrett, 2003). The efficacy of the FRIENDS programme has more recently been demonstrated in a sample of German children (Essau, Conradt, Sasagawa, &

Ollendick, 2012). The authors identified perfectionism and avoidant coping as mediators of improvements in anxiety scores. In the UK, Stallard, Simpson, Anderson and Goddard (2008) reported a decrease in anxiety symptoms among children who had taken part in the FRIENDS programme at 3-month and 12-month follow up, in comparison to their levels of symptoms when initially assessed six months before the programme, but not in comparison to their symptoms

immediately before treatment. This study was limited by a lack of a control group and a relatively small sample (N = 63). In a review by Neil and Christensen (2009), eleven of the sixteen universal trials included reported significant reductions in anxiety symptoms between the intervention and control conditions, with effect sizes (Cohen’s d) ranging from 0.31-1.37. Despite these promising findings, there are some limitations to the evidence base for universal preventions. In Barrett et al. (2006), for example, although reductions in anxiety were maintained three years later, 47% of participants were not followed up at this point. Despite the

encouraging findings from outside the UK, the case for introducing programmes into UK schools would benefit from more evidence of their efficacy within a UK setting (though see Stallard et al., 2014). The scale and associated effort and cost of implementing universal programmes may also act as a barrier to their introduction.

In a bid to focus interventions on those who need it, selective interventions (those which target children who are at risk of developing anxiety) and indicated

interventions (those which target children demonstrating early symptoms of the disorder) have been designed. For example, Ginsburg (2009) evaluated the effectiveness of the CAPS programme (Child Anxiety Prevention Study) on 40 children aged 7-12 who had a parent with an anxiety disorder. The programme targets children and parents and features problem solving, improving knowledge and communication skills and reducing risk factors such as parental overprotection.

At 6-month and 12-month follow ups, none of the children randomly assigned to the intervention group had developed an anxiety disorder whereas 30% of the children assigned to the ‘wait-list’ group had. In a large study by Dadds and

47 colleagues (1997, 1999), a total of 1786 children were screened for anxiety using teacher nomination and child self report, with parents of identified children given a diagnostic interview about their child. 128 children were then assigned to an intervention or monitoring group, based on which school they attended (schools were matched for size, socioeconomic and socio-demographic status). Like

FRIENDS, the intervention was based on the Coping Koala program (Barrett, Dadds, et al., 1996) and was based on Kendall’s (1990) FEAR plan in which F stands for

‘feeling good by learning to relax’, E stands for ‘expecting good things to happen through positive self talk’, A is for ‘actions to take in facing up to fear stimuli’ and R is for ‘rewarding efforts to tackle fears and worry’. Although no significant

differences were found between the two groups immediately after treatment, fewer children in the intervention group were diagnosed with anxiety at six month follow up. These differences disappeared at 12 month follow up, however at two years-old, children in the intervention group were significantly less likely to be diagnosed with an anxiety disorder over the telephone by a clinician who was blind to the intervention status of the children.

Whereas efforts have been made to develop universal anxiety interventions in childhood, and programmes which target children at risk of developing an anxiety disorder, there are a lack of such interventions for functional somatic symptoms.

Given the strong association between anxiety and somatic symptoms in children, it may be the case that interventions such as the FRIENDS program which has been shown to reduce anxiety, also reduces levels of somatic symptoms in children, but this has yet to be tested. Psychological interventions for children who are currently experiencing high levels of somatic symptoms have been evaluated however, and there is evidence that cognitive behavioural therapy (CBT) can be effective in reducing symptoms. For example, in a randomized controlled trial (Robins, Smith, Glutting, & Bishop, 2005), children recently diagnosed with recurrent abdominal pain were assigned into a group receiving standard medical care (n = 29) or a group receiving standard medical care plus five 40 minute long CBT interventions (n = 40), administered conjointly to them and to their parent. Children who had been

assigned to the CBT group reported significantly less abdominal pain both

48 immediately after the intervention and at one year follow up, and significantly fewer school absences than children who received standard medical care only.

Other studies have also shown positive effects for CBT on abdominal pain in children, at three and 12-month follow ups (Sanders et al., 1989; Sanders,

Shepherd, Cleghorn, & Woolford, 1994). A cognitive behavioural intervention which jointly targets anxiety and physical symptoms ‘TAPS’ (Treatment of Anxiety and Physical Symptoms) has also shown promise. Warner et al. (2011) evaluated the effectiveness of the programme on 40 children with functional somatic symptoms (predominantly gastrointestinal symptoms) who also met criteria for an anxiety disorder. Post intervention, nearly half (45%) of the children who were randomly assigned to receive the intervention (n = 20) met criteria for an anxiety disorder compared to none of the 19 children in the control group. The intervention group also reported being significantly less bothered by their symptoms on the Children’s Somatisation Inventory, and effects were maintained at three months.

Recently, Ecclestone et al. (2014) published a systematic review into the effects of psychological interventions delivered face to face for chronic and recurrent pain in children and adolescents. The majority of the 37 randomised controlled trials they included were interventions for headaches (n = 20) but the review also considered interventions for abdominal pain (n = 9) and other types of pain. For headaches, psychological interventions reduced pain post treatment and at follow up (between three and 12 months post treatment) and also anxiety post treatment, but not at follow up. Ecclestone et al. (2014) combined the other pain conditions into one group, and reported improvements in pain post treatment, but not at follow up, and no improvements in anxiety or depression post treatment or at follow up. The psychological interventions included behavioural strategies such as relaxation as well as cognitive coping skills, but the review did not distinguish between different types of psychological therapy, so it is difficult to draw conclusions about which programmes of intervention were the most successful.

In conclusion, evidence suggests that anxiety in children is treatable and preventable. Although there is a lack of studies which assess interventions for somatic symptoms in children who do not present in primary care, evidence

49 indicates that these symptoms too can be reduced through psychological

interventions, though more research is needed to establish how long these reductions are maintained.