2. Literature Review
2.7 Reactive versus preventative CBT intervention
The following sections consider the use of CBT support via both reactive (i.e. with higher-level anxieties) and preventative (i.e. early intervention with initial anxiety symptomatology) means in order to illustrate how CBT support may address anxiety of differing severities.
2.7.1 Reactive CBT interventions
Kendall (1994) conducted an RCT in which 47 students (9-13 years) with diagnosed anxiety disorders were enlisted to either intervention or control groups. Group performance comparison illustrated that 64% of participants in the intervention group did not meet diagnostic criteria for an anxiety disorder post-intervention; a trend maintained at a one-year follow-up. Whilst these findings provided an initial rationale for the use of CBT with those children and young people experiencing the greatest anxiety, ethical concerns are raised regarding the use of a control group for comparison purposes.
In contrast, Manassis et al., (2002) employed group-based and individualised CBT for addressing the anxiety disorders of 8-12 year olds. 78 participants were randomly allocated to either group-based or individualised CBT programmes, with both groups demonstrating reductions in anxiety symptomatology post-intervention. Participants diagnosed with social phobia made most gains when provided with individualised CBT. These findings illustrate the effectiveness of different CBT delivery methods; however the conclusions drawn may have been strengthened by using a wait-list comparison group, an adaptation which would negate some of the criticism made towards Kendall’s use of a control group.
Silverman et al. (1999) sought to demonstrate the efficacy of group CBT for addressing anxiety disorders in children and young people. 41 participants
40 (6-16 years) were allocated to either treatment or wait-list comparison conditions. Post-intervention, 13% of wait-list participants no longer met diagnostic criteria, compared to 64% of intervention participants. These benefits for intervention attendees continued at 3-month follow-up and remained at 12-month follow-up. These findings: a) support the use of group CBT in schools and b) indicate that benefits may continue over time, raising questions regarding the mechanisms of change within CBT, and which elements of CBT input may enable participants to continue to manage their emotions post-intervention. Potential mechanisms of change are discussed further in section 2.8.
2.7.2 Preventative CBT interventions
Preventative CBT-based interventions may be preferable to reactive support, as the intention is to support children and young people’s well-being at the earliest opportunity, to avoid the need for individualised, specialist support with higher-level needs at a later date, as outlined in Figure 2.1.
The following studies consider the efficacy of CBT when used in a preventative sense within schools, providing support for the use of CBT for early interventionwithanxiety.
Dadds et al. (1997) investigated the efficacy of indicated CBT support for both preventing and addressing anxiety disorders in 128 participants (7-14 years). They compared an intervention and control group, with the former group accessing 10 sessions of CBT. Approximately half of participants in the intervention group no longer met criteria for anxiety disorders post- intervention. Furthermore, whilst 16% of the intervention group developed an anxiety disorder 6 months after the study, 54% of the control group developed a disorder during the same time period. These results suggest that CBT may offer an effective means of addressing anxiety disorders, with
some indication, of CBT support preventing anxiety disorders at 6-month
follow-up, albeit these trends are from one study and would require replication across more recent research to increase the evidence for the use of CBT as a preventative intervention.
41 Similarly, Mifsud and Rapee (2005) conducted an RCT comparison study into the effectiveness of indicated CBT for reducing initial anxiety symptomatology. Participants (8-11yrs) were identified as experiencing early indications of anxiety via a screening process (Revised Children’s Manifest Anxiety Scale, Reynolds and Richmond, 1978). Participants were allocated to an intervention group (n=50) or to a wait-list comparison group (n=41). 8 CBT sessions were delivered to small groups of 10 participants. Intervention participants demonstrated significantly greater reductions in anxiety post- intervention and this progress was replicated 4-months after the intervention. This study suggests the potential for the use of group-based CBT for intervening early with anxiety.
In a key UK study, Stallard et al. (2005) evaluated the universal delivery of FRIENDS across six primary schools. 197 pupils (9-10 years) participated. These pupils showed significantly reduced anxiety and significantly improved self-esteem post-intervention. 190 participants rated the ‘acceptability’ of this programme with responses indicating that 154 (81%) thought FRIENDS was ‘fun’ and 147 (77.4%) would recommend FRIENDS to their peers. These findings provide initial indications of the effectiveness of CBT when provided to whole-class populations and thereby support the notion of school-based CBT interventions.
Stallard et al. (2008) built upon this initial study, via another universal CBT intervention of the ‘FRIENDS’ programme. This study extended the evidence base for the use of CBT within UK Schools and provided tentative support for the preventative role of CBT via universal level delivery, in addition to the above indicated interventions. A quasi-experimental study with a pre- test/post-test one-group design included 106 participants from the same age range (i.e. 9-10 years) from 4 classes across 3 junior schools in the UK. Whole class sessions were embedded into the curriculum for one term, with participants displaying statistically significant improvements in anxiety post- intervention and at a 12-month follow-up, again suggesting that such support can be successfully embedded within the classroom context whilst producing longer-term positive outcomes. These findings are however limited by the
42 lack of a control group, meaning the natural maturation rate of pupil progress was not recorded.
With the emphasis upon early intervention within policies (TaMHS, DCSF, 2008; IAPT, Department of Health, 2006), it is surprising that (as highlighted in section 2.7) many studies have instead prioritised responsive intervention with those children and young people with the highest-level needs. For example, in the aforementioned review developed by the current author (Lake, 2012) only 4 studies were of a preventative nature.
Those papers outlined hitherto illustrate a range of studies investigating the use of CBT with children and young people experiencing anxiety; the number of studies reviewed here is by no means exhaustive. These studies contribute to the increasingly well-established evidence base for the implementation of CBT with young people experiencing such needs; however, many researchers within those studies reviewed indicated that they were seeking to intervene with populations experiencing anxiety needs of a greater severity. Given the cited importance of early intervention work (TaMHS, DCSF, 2008; IAPT, Department of Health, 2006) there remains a need for further investigation into the efficacy of preventative interventions, particularly with UK-based populations.
2.7.2.1 Level of intervention
The studies outlined in sections 2.5-2.7.2 include 26 universal, 11 selective and 8 indicated CBT interventions, plus one individualised intervention.
The majority of studies reviewed were therefore implemented at a universal level of delivery, enhancing the evidence base for that particular format of CBT intervention. This is perhaps surprising given that several studies portrayed an intention to intervene with higher-level anxieties, which would typically warrant individualised support.
However, there appears to be less research into the use of small-group preventative (i.e. indicated) CBT interventions. Indeed, in a meta-review of 52 systematic reviews of mental health interventions, Weare and Nind (2011)
43 noted that only six focused on indicated/targeted interventions, whilst 14 highlighted the positive impacts of embedding indicated/targeted interventions within universal programmes of support.
Further research may also be required into the efficacy of indicated CBT delivery with a UK-based population, as the need for indicated interventions has been underlined by British legislation and Government policy (Department of Health, 2011; TaMHS, DCSF, 2008; IAPT, Department of Health, 2006).
2.7.2.2 Age of participants
Section 2.7.2.1 considered the level of intervention apparent within those studies discussed, highlighting the need for further research into the efficacy of indicated CBT interventions. Similarly, when the age-ranges of participants within the systematic review are considered, further shortcomings are identified within the existing evidence base.
Of those studies outlined thus far, participant populations have included a range of ages. The eldest participants included were approximately 14 years of age (Dadds et al., 1997), whilst the youngest participants were 7 years of age (ibid).
However, It is notable that those English studies included (i.e. Stallard et al., 2005; Stallard et al., 2008; Paul, 2011; Clarke, 2011) focus primarily upon supporting pupils within primary school settings (i.e. up to 11 years). This is significant, as more research into the use of CBT with an older British participant population appears warranted, given the views of local stakeholders (outlined in section 2.1), regarding the need to intervene with those anxieties experienced by secondary-age students within local schools.