J2.Stopa Thesis

The prevention of childhood anxiety in socioeconomically disadvantaged communities:
A universal school-based trial

Running head: PREVENTION OF ANXIETY IN DISADVANTAGED COMMUNITIES
The prevention of childhood anxiety in socioeconomically disadvantaged communities:
A universal school-based trial
Jayne Stopa
University of Queensland
A dissertation submitted for the degree of Professional Doctorate in Clinical Psychology
School of Psychology - University of Queensland
Date: 17th June 2010
i
PREVENTION OF ANXIETY IN DISADVANTAGED COMMUNITIES
Declaration of Originality
I declare that this dissertation is comprised of my own original work, and has not previously
been submitted for a degree or award at any other university. To the best of my knowledge,
this dissertation contains no material which has been previously published or written by
another person, except where due reference has been made within the dissertation itself.
Signed: __________________________
Date: ___________________________
ii
Acknowledgements
I would like to express my eternal gratitude to my supervisor, Dr Paula Barrett, for

her supervision, guidance, and friendship for the duration of this research journey. Thank
you for supporting me, for sharing your knowledge, and for your enduring enthusiasm and
positive attitude towards my research.
I would also like to thank my husband, James, who has been by my side for the entire
five years of my postgraduate career. Thank you for loving me and believing in me, and for
your patience and understanding when things seemed impossible. Without your unwavering
love and support, I would never have achieved my goals.
Thank you to my parents for their unconditional love and support. You have always
worked hard to give me the best opportunity to succeed in every endeavour, and provided me
with support and encouragement to work hard and reach my goals. You have always
believed in me, and I could not have done this without you.
A big thank you to Dr Philippe Lacherez, who provided me with invaluable assistance
with the statistical aspects of my research. Thank you also to Dr Temesgen Kifle, who
helped me to solve some rather challenging problems with my data set.
I would also like to thank all those who were directly involved in various aspects of
this project, including Dr Kristy Pahl, Dr Leah Brennan, Alison Burnell, Meike Burow, and
all the staff members of Pathways Health and Research Centre. Thanks also to Dr Lara
Farrell, who provided me with a lot of support and guidance during the preliminary stages of
this research.
Special thanks must also go to Felisa Golingi, who has shared a large proportion of
this journey with me and provided me with invaluable support and assistance, and most
importantly, friendship.
Lastly, a special thank you to all the staff, students, and parents of Crestmead State
School, Burrowes State School, and Waterford West State School, who participated in this
research. It was a pleasure working with you all.
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Abstract
Anxiety disorders are among the most prevalent psychiatric disorders in children and
adolescents, with up to 25% of children experiencing clinical anxiety at some point (Boyd,
Kostanski, Gullone, Ollendick, & Shek, 2000; Essau, Conradt, & Petermann, 2000; Neil &
Christensen, 2009; Tomb & Hunter, 2004). The impact of childhood anxiety is far-reaching,
resulting in compromised functioning across a range of psychosocial domains, and typically
persisting well into adolescence and adulthood (Pine, 1997). This issue is compounded by
the fact that the majority of children with anxiety disorders do not receive the treatment they
require (Esser, Schmidt, & Woemer, 1990; Hirschfeld et al., 1997; Olfson, Gameroff,
Marcus, & Waslick, 2003; Sawyer, Kosky, Graetz, Arney, Zubrick, & Baghurst, 2000).
Consequently, research efforts have prioritised the evaluation of universal interventions for
anxiety delivered within the school system, providing a more cost-effective model of
intervention. Research to date has been promising, indicating that universal school-based
prevention of anxiety is effective in reducing internalising symptoms in children and
adolescents (Neil & Christensen, 2009).
The issue of childhood anxiety is magnified in areas of socioeconomic disadvantage,

with children from these populations at an increased risk of developing anxiety disorders and
other psychiatric disorders (Kessler et al., 1994; Miech, Caspi, Moffitt, Entner Wright, &
Silva, 1999; Xue, Leventhal, Brooks-Gunn, & Earls, 2005). Children from disadvantaged
communities less likely to receive psychological assistance (Cunningham & Frieman, 1996;
Kazdin & Mazurick, 1994; Kazdin & Wassell, 1999; Misfud & Rapee, 2005), and face
significant barriers to accessing the treatment they require (Owens et al., 2002). Despite the
greater risk of anxiety faced by children living within socioeconomically disadvantaged
communities, there is a paucity of research investigating the prevention of childhood anxiety
disorders specifically within disadvantaged populations.
The primary objective of this thesis was to evaluate the effectiveness of a well-
validated cognitive-behavioural intervention for childhood anxiety, the FRIENDS for Life
program, when delivered as a universal school-based intervention within a socioeconomically
disadvantaged region. The study involved a cohort of 963 children from Grades 5, 6, and 7,
who were enrolled at one of three primary schools within this region. Children from all
schools participated in a teacher-led, manualised 12-session intervention for anxiety,
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delivered during regular classroom time within one regular school term. All participants
completed a package of self-report measures assessing levels of anxiety and depressive
symptomatology, as well as self-esteem, coping skills, and psychosocial difficulties, prior to
commencing the intervention. These measures were readministered at the completion of the
intervention, and again at 12 months post-intervention to participants in Grades 6 and 7
(children from Grades 5 and 6 during the intervention year) only.
Results indicated significant reductions in anxiety and depressive symptomatology

from pre to post-intervention, with these gains maintained at 12 months follow-up. Peer
problems and conduct problems were significantly lower both at post-intervention and again
at 12-months follow-up. Use of cognitive avoidance and behavioural avoidance strategies
also significantly decreased, whilst self-esteem and cognitive behavioural problem-solving
increased significantly over time. The findings further validate the FRIENDS for Life
program, and demonstrate it’s effectiveness as a universal school-based intervention for
children within socioeconomically disadvantaged populations. Clinical implications of these
results are discussed, along with limitations and directions for future research.
v
Table of Contents
Declaration of originality …..……………………………………………………………ii

Acknowledgements ……………………………………………………………………….iii
Abstract ….………………………………………………………………………………..iv
Table of Contents …………………………………………………………………………vi
List of Tables …....………………………………………………………………………viii
List of Figures …..…………………………………………………………………………ix
List of Abbreviations ..…………………………………………………………………….x
CHAPTER ONE: CHILDHOOD ANXIETY DISORDERS …..………………………….1
Introduction …..……………………………………………………………………1
Anxiety in Children ……………………………………………………………………4
Epidemiology …………………………………………………………………..……5
Impact ……………………….……………………………………………………….9
CHAPTER TWO: RISK & PROTECTIVE FACTORS FOR CHILDHOOD
ANXIETY ………………………………………………………………………………...14
Risk Factors …..………………………………………………………………………14
Biological Factors …...……………………………………………………………15
Psychological Factors ………………………………………………………………20
Environmental Factors ….…………………………………………………………28
Protective Factors ………….…………………………………………………………42
Child Protective Factors ..…………………………………………………………43
Family & Environmental Protective Factors ………………………………………47
CHAPTER THREE: TREATMENT OF CHILDHOOD ANXIETY DISORDERS …….51
Individual Cognitive Behaviour Therapy …………………………………………..51
Group Cognitive Behaviour Therapy ...…………………………………………….55
CHAPTER FOUR: PREVENTION OF CHILDHOOD ANXIETY DISORDERS ….…61
Levels of Prevention …………………………………………………………………..64
Indicated Prevention ………………………………………………………………69
Selective Prevention ………………………………………………………………71
Universal Prevention ………………………………………………………………73
CHAPTER FIVE: CHILDHOOD ANXIETY IN DISADVANTAGED
COMMUNITIES ………………………………………………………………………81
Prevalence of Childhood Psychopathology in Disadvantaged Communities .……82
Neighbourhood effects of socioeconomic disadvantage …..………………………84
Barriers to Mental Health Service Utilisation …….………………………………...87
Breaking down the barriers – School-based prevention …………………………..90
Prevention of childhood anxiety in disadvantaged communities …...……………91
The Current Study …………………………………………………………………..96
CHAPTER SIX ..…..……………………………………………………………………100
Method ……………………………………………………………………………….100
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Participants ……….....……………………………………………………………100
Measures …………………………………………………………………………103
Procedure …………………………………………………………………………106
Intervention protocol ………………………..……………………………………110
CHAPTER SEVEN …..…………………………………………………………………116
Results ……...……..…………………………………………………………………116
CHAPTER EIGHT ……..………………………………………………………………130
Discussion …...………………………………………………………………………130
Clinical Implications ...……………...……………………………………………141
Limitations ……………………………...………………………………………..144
Future Directions ...……………………………………………………………….147
REFERENCES …………………………………………………………………………152
APPENDIX …...……...…………………………………………………………………212
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List of Tables
Table 1
Strengths and Weaknesses of Indicated, Selective and Universal approaches to
School-based Prevention ……………………………………………………………………67
Table 2
Measures of the SEIFA index of socioeconomic disadvantage by SLA ……………………102
Table 3
FRIENDS for Life components delivered per session …………………………………….114
Table 4
Sample size for all measures analysed, across time points ………………………...……….117
Table 5
Sample sizes for each school, by grade and gender ……………………………...……….118
Table 6
Mean and standard deviation for all clinical outcome measures at baseline ……………119
Table 7
Mean and standard deviation for all measures at pre-intervention, post-intervention
and follow-up …………………………………………………………………………123
Table 8
Means and standard deviations for difference between pre-intervention and
post-intervention scores ………………………………………………………………….125
Table 9
Pearson bivariate correlations between psychosocial predictors and difference
scores in outcome ……………………………………………………………………….128
viii
List of Figures
Figure 1
Variables used to calculate the index of relative socioeconomic disadvantage …………..101
Figure 2
Change in risk status over time ………………………………………..…………………112
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List of Abbreviations
ADHD Attention-Deficit Hyperactivity Disorder

CBT Cognitive Behavioural Therapy
CBT+FAM Cognitive Behavioural Therapy + Family Component
CBT+PAM Cognitive Behavioural Therapy + Parental Anxiety Management
CD Conduct Disorder
CDI Children’s Depression Inventory
CSCY Coping Scale for Children and Youth
DSM Diagnostic and Statistical Manual of Mental Disorders
DSM-III Diagnostic and Statistical Manual of Mental Disorders
DSM-III-R Diagnostic and Statistical Manual of Mental Disorders,
Edition 3, revised
DSM IV Diagnostic and Statistical Manual of Mental Disorders,
Edition 4
DSM IV-TR Diagnostic and Statistical Manual of Mental Disorders,
Edition 4, Revised
FCBT Family Cognitive Behaviour Therapy
FESA Family-based Education, Support, and Attention
FGCBT Family Group Cognitive Behaviour Therapy
GAD Generalised Anxiety Disorder
GCBT Group Cognitive Behaviour Therapy
ICBT Individual Cognitive Behaviour Therapy
OAD Overanxious Disorder
OCD Obsessive Compulsive Disorder
ODD Oppositional Defiant Disorder
PD Panic Disorder
PTSD Post Traumatic Stress Disorder
RCMAS Revised Children’s Manifest Anxiety Scale
SAD Separation Anxiety Disorder
SCAS Spence Child Anxiety Scale
SD Standard Deviation
SDQ Strengths and Difficulties Questionnaire
SEI Self Esteem Inventory
SES Socioeconomic Status
SOP Social Phobia
SP Specific Phobia
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CHAPTER ONE: CHILDHOOD ANXIETY DISORDERS
Childhood anxiety disorders are among the most prevalent forms of childhood
psychopathology, with serious immediate and prevailing implications for sufferers, their
families, and society at large (Donovan & Spence, 2000). Children with anxiety disorders are
more likely to have difficulties with social functioning, low academic achievement, and low
self-esteem, among other indicators of poor psychosocial adjustment (Pine, 1997). In light of
such factors, early research efforts have prioritised the development of interventions for
childhood anxiety, both at the individual and, more recently, the group level, with promising
results. Despite ongoing refinement and evaluations of such interventions, the fact remains
that most children with anxiety disorders do not receive the treatment they require (Esser,
Schmidt, & Woemer, 1990; Hirschfeld et al., 1997; Olfson, Gameroff, Marcus, & Waslick,
2003; Sawyer et al., 2000), whilst many of those who do either terminate prematurely
(Kazdin, 1996), or continue to experience ongoing difficulties (Barrett, Dadds, & Rapee,
1996; Donovan & Spence, 2000; Last, Perrin, Hersen, & Kazdin, 1996).
The poor utilisation and response to treatment mentioned above suggests that
addressing established disorders is not the most optimal intervention model for childhood
anxiety (Barrett & Turner, 2001). As such, research interests have shifted to prevention as a
more timely and effective method to reduce the burden of childhood anxiety on the wider
community. To address issues of accessibility, many researchers have focused on the
delivery of preventative interventions for anxiety through the school system, overcoming
many barriers which have typically prevented families from accessing individual treatment
(McLoone, Hudson, & Rapee, 2006; Owens et al., 2002). Empirical evaluation of such
interventions has yielded positive results, with significant growth in the literature validating
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the use of universal school-based prevention for childhood anxiety across different ages and
developmental levels, both within Australia and internationally (Neil & Christensen, 2009).
Whilst preventative interventions for anxiety have been validated extensively in
private schools and public schools from more affluent catchments, little research has focused
exclusively on the prevention of childhood anxiety disorders in communities of recognised
low socioeconomic status (SES). This is despite the fact that mental illness is
overrepresented in socioeconomically disadvantaged communities, with both adults and
children from low SES communities significantly more likely to experience psychological
distress (Buckner & Bassuk, 1997; Drukker, Kaplan, Feron, & van Os, 2003), as well as other
health problems (Curtis, Dooley, Lipman, & Feeny, 2001). These communities face a unique
set of difficulties, including higher rates of poverty, unemployment, familial instability, and
low education, culminating in an increased risk for anxiety. Whilst research within low SES
populations understandably presents greater methodological challenges, it is unfortunate that
researchers have largely neglected this at-risk population, who arguably stand to benefit the
most from such interventions in the long term.
The objective of the present doctoral thesis is to expand upon the body of literature
examining the prevention and treatment of childhood anxiety, focusing specifically upon the
issue of childhood anxiety within socioeconomically disadvantaged communities. The
primary goal of this study is to investigate the effectiveness of a universal school-based
intervention for childhood anxiety, delivered to upper primary school-aged children from
three public schools located within a recognised low SES region. Specifically, it seeks to
examine both the immediate and long-term effects of the intervention, not only in terms of
the primary outcome measure of anxiety symptomatology, but additionally depressive
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symptomatology, self-esteem, and coping skills. It is hoped that the findings of this research
advance the argument for standardised, curriculum-based anxiety intervention and prevention
programs in these populations, which have thus far been neglected in both research and
practice.
The aim of the current chapter is to provide an overview of anxiety in school-aged
children, through investigating prevalence rates, epidemiology and comorbidity of childhood
anxiety disorders. It also provides a synopsis of both the immediate and longitudinal impact
of childhood anxiety, in terms of psychological wellbeing and psychosocial functioning.
Chapter Two provides a review of recognised risk factors for childhood anxiety, followed by
an overview of protective factors noted within the literature. Chapter Three offers a review
of the literature on treatment for childhood anxiety disorders, focusing primarily on the
development of cognitive behavioural therapy (CBT) as an individual therapy for anxiety, to
the progression towards group-based CBT for childhood anxiety. Chapter Four provides a
comprehensive review of the shift from treatment to prevention of childhood anxiety. It
examines three different levels of prevention, and reviews available prevention literature at
each of the three levels, focusing particularly on universal prevention delivered in the school
setting. Chapter Five is concerned specifically with the association between psychopathology
and socioeconomic disadvantage. It also reviews barriers to mental health services prevalent
in low SES populations, prior to providing an overview of the rationale and hypotheses of the
current study. The methodology for the current research is presented in Chapter Six, with the
results and discussion covered in Chapter Seven and Chapter Eight respectively.
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Anxiety in Children
Anxiety is a normal and evolutionarily adaptive emotional response to a real or
imagined threat, designed to aid in survival and the avoidance of danger. Anxiety responses
involve three primary components: physiological (e.g. heightened autonomic responses),
cognitive (e.g. threat perception), and behavioural (e.g. avoidance) (Essau & Peterman,
2001). All children experience anxiety as part of their normal social and emotional
development, and sources of anxiety in childhood and adolescence vary as a function of
developmental stage (Ollendick, King, & Yule, 1994). For example, anxiety in infants and
younger children may occur in response to separation from the attachment figure, whilst in
later childhood and adolescence, anxiety is more likely to be triggered by challenging
situations, social fears, and academic stressors (Warren & Sroufe, 2004). In essence,
childhood fears generally shift from concrete, external stimuli, to internalised and abstract
stressors across the lifespan (Koplewicz, 1996), which reflects the varying range of
experiences to which children are exposed over time. It is therefore important to be mindful
of normative anxiety contexts and developmentally appropriate fear in assessing anxiety in
children (Ollendick et al., 1994), and to acknowledge that the experience of anxiety does not
necessarily constitute disordered functioning.
Whilst anxiety responses are part of the normal childhood experience, these responses
become problematic when they persistently occur in response to an unreasonable perception
of threat, and at an intensity that is disproportionate to the objective threat (Essau &
Peterman, 2001). In this way, anxiety ceases to be adaptive, resulting in functional
impairment and interfering with aspects of everyday life. Diagnostically, the degree and
duration of interference in the context of the stressor may be indicative of clinical anxiety.
The hallmark feature of anxiety disorders in children is worry, which may manifest as overt
4
distress, or more implicitly through poor concentration and irritability. Behavioural
avoidance of anxiety-provoking stimuli is also common, in conjunction with a range of
somatic symptoms, including restlessness, headaches, fatigue, appetite loss, muscle tension,
nausea and vomiting, enuresis, and sleep disturbances (Essau & Peterman, 2001). Anxiety
disorders can therefore result in significant impairment in everyday functioning across social,
emotional, academic, and vocational domains.
It has been little over two decades since researchers first started to extensively foray
into the nebulous area of childhood anxiety; indeed prior to this, it was believed that children
lacked the cognitive capabilities to experience internalising disorders (Essau & Peterman,
2001). The current empirical understanding of childhood anxiety however places it alongside
adult anxiety in terms of basic phenomenology (Laurent & Ettelson, 2001; Turner & Barrett,
2003). Accordingly, the field is now afforded significant research attention, which more
accurately reflects the magnitude of the issue in child populations. The following section
provides an epidemiological overview of childhood anxiety disorders, and reviews the impact
of childhood anxiety upon other spheres of psychosocial functioning.
Epidemiology
Anxiety disorders are consistently cited as the most common type of disorders in
childhood (Beidel, 1991; Costello, Egger, & Angold, 2005; Essau, Conradt, & Petermann,
2000; Kashani & Orvaschel, 1988; Messer & Beidel, 1994). The most recently reported
prevalence rates range between 4% and 25% (Boyd, Kostanski, Gullone, Ollendick, & Shek,
2000; Essau et al., 2000; Neil & Christensen, 2009; Tomb & Hunter, 2004), with up to 28.8%
of children developing an anxiety disorder during their lifetime (Kessler, Berglund, Demler,
Jin, & Walters, 2005). Differences between reported prevalence rates are due to
5
methodological variations, including changes to diagnostic criteria over time, clinical cut-offs
used, diagnostic measures and sampling methods employed. Prevalence rates also vary
according to developmental stage; some disorders, such as separation anxiety disorder (SAD)
and specific phobia (SP), are more common in younger children, whilst others such as social
phobia (SOP) and panic disorder (PD), are more prevalent among adolescent samples.
Costello, Mustillo, Erkanli, Keeler, and Angold (2003) report that, collapsed across
diagnosis, prevalence rates tend to peak around the age of 9 to 10 years. Anxiety disorder
prevalence rates are typically twice as high for girls than for boys (Lewinsohn, Gotlib,
Lewinsohn, Seeley, & Allen, 1998). Rather than indicating a genuine predisposition for
anxiety in females, it has been argued that these prevalence rates may reflect the fact that
girls are more likely to report worries, fears, and symptoms of anxiety than boys (Bell-Dolan,
Last, & Strauss, 1990; Essau & Peterman, 2001; Muris, Meesters, Merckelbach, Sermon, &
Zwakhalen, 1998; Silverman & Treffers, 2001; Silverman, Greca, & Wasserstein, 1995).
The course of childhood anxiety disorders is typically chronic, and in many cases,
childhood anxiety is a precursor for long-term clinical presentations well into adolescence
and adulthood (Cartwright-Hatton, McNicol, & Doubleday, 2006). Anxiety disorders are
particularly robust if left untreated, and rarely remit without intervention (Costello, Egger, &
Angold, 2004). One study of a group of children aged from 6 to 19 years found that on
average, those with untreated anxiety disorders had experienced clinical difficulties for 4
years, with 30% of those who had recovered experiencing a recurrence of anxiety (Keller,
Lavori, Wunder, Beardslee, Schwartz, & Roth, 1992). Even where treatment is procured,
between 30% and 40% of children may continue to meet diagnostic criteria for an anxiety
disorder post-intervention (Barrett, Rapee, Dadds, & Ryan, 1996; Kendall, 1994). For those
who do successfully respond to treatment, recurrences later in life are common, with some
6
children going on to develop new anxiety disorders as well as other types of psychological
disorders (Last et al., 1996). Anxiety disorders in childhood are also predictive of
disturbances in later life such as substance abuse (Kessler et al., 1996), suicidality, and
personality psychopathology (Rudd, Joiner, & Rumzek, 2004), and confer a significant risk
for both concurrent and successive comorbidity with a range of other disorders, both in
community and clinical populations.
Childhood anxiety disorders have high rates of comorbidity with many internalising
and externalising disorders (Angold, Costello, & Erkanli, 1999; Brady & Kendall, 1992;
Essau & Peterman, 2001), with reported comorbidity rates for childhood anxiety disorders in
community samples of up to 39% (Anderson, Williams, MgGee, & Silva, 1987; Kashani &
Orvaschel, 1990). Anxiety disorders are commonly comorbid with each other during
childhood, and a high percentage of children with an anxiety disorder diagnosis also meet
criteria for a second, concurrent disorder. Comorbidity in generalised anxiety disorder
(GAD), the most frequently diagnosed childhood anxiety disorder, is very common. A study
involving a community sample found that up to 50% of children with overanxious disorder
(OAD; later subsumed under the new diagnosis of GAD) also met criteria for SAD (Kashani
& Orvaschel, 1990). Similarly, 46% of children diagnosed with SAD also fulfilled criteria
for SOP (Kashani & Orvaschel, 1990). The significant rates of comorbidity between other
pairs and clusters of childhood anxiety disorders have been discussed in detail elsewhere
(Curry, March, & Hervey, 2004). Clearly, comorbidity of anxiety disorders is a common
problem, resulting in a more complex constellation of difficulties for anxious children.
The link between childhood anxiety disorders and depressive disorders has also been
well established. Anxiety disorders are more frequently concurrently comorbid with
7
depressive disorders than with either attention-deficit hyperactivity disorder (ADHD),
conduct disorder (CD), oppositional defiant disorder (ODD), or substance abuse disorders
(Costello et al., 2003; Curry et al., 2004; Verduin & Kendall, 2003). A comprehensive
review of comorbidity between the two disorder clusters reported rates of comorbid
depression ranging between 5% and 69% in children and adolescents with anxiety disorders
(Angold et al., 1999). Children and adolescents with clinical anxiety were found to be 8.2
times more likely to meet criteria for a depressive disorder than children without clinical
anxiety (Angold et al., 1999; Costello et al., 2005). Similarly, rates of comorbid anxiety in
children and adolescents with depression have been reported to range up to 75% (Angold et
al., 1999), indicating the high degree of overlap between the two disorders.
The negative impact of comorbid anxiety and depression in childhood is typically
greater than that of either disorder alone, with higher levels of psychopathology, severity of
symptoms, and greater functional impairment all associated with comorbidity (Masi et al.,
2004; Seligman & Ollendick, 1998). Further to this, comorbid anxiety and depression may
constitute an increased risk of suicide in young people (Cole, Peeke, Martin, Truglio, &
Seroczynski, 1998), given that anxiety and depression are risk factors for suicide in their own
right. Additionally, research demonstrates that up to 84% of child and adolescent suicide
victims may suffer from comorbid mental disorders (Shafii, Steltz-Lenarsky, Derrick,
Beckner, & Whittinghill, 1988). With regard to psychosocial functioning, children with
comorbid anxiety and depression are at a distinct disadvantage. In research conducted by
(Masi, Favilla, Mucci, & Millepiedi, 2000) involving children aged between 8 and 18 years,
those with comorbid anxiety and depression had higher levels of functional impairment and
severity of anxiety of symptoms, than those with anxiety alone.
8
Comorbidity of anxiety and depressive disorders is not always concurrent; a temporal
relationship between anxiety and depression has been found for both clinical and community
populations (Boyd & Gullone, 1997; Brady & Kendall, 1992; Cole et al., 1998; Orvaschel,
Lewinsohn, & Seely, 1995; Pine, Cohen, Gurley, Brook, & Ma, 1998; Seligman & Ollendick,
1998). There is a successive pattern of comorbidity between the two disorders, whereby
anxiety disorders in children may longitudinally predict the development of depressive
disorders in adolescence and at later stages of the life course (Angold, Costello, &
Worthman, 1998; Hankin et al., 1998; McGee, Feeham, Williams, & Anderson, 1992;
Silberg, Rutter, & Eaves, 2001; Velez, Johnson, & Cohen, 1989). A longitudinal study by
Kovacs, Gatsonis, Paulauskas and Richards (1989) found that in children with comorbid
depression and anxiety, the latter preceded depression in two-thirds of cases. This is
consistent with later longitudinal research by Orvaschel et al., (1995), who found that
approximately 64% of adolescents with diagnosable anxiety went on to develop a secondary
diagnosis of major depressive disorder. More support has been found through research
demonstrating anxiety symptomatology in children predicts higher levels of depressive
symptoms later in adolescence (Cole et al., 1998), and that children with comorbid anxiety
and depression tend to be older than children with anxiety alone (Strauss, Lease, Last, &
Francis, 1988).
Impact
The impact of childhood anxiety disorders on the individual can be both pervasive
and far-reaching, affecting many aspects of social functioning over time. In school-aged
children, anxiety has been shown to predict below average academic achievement (McLoone
et al., 2006), with longitudinal research demonstrating the link between anxiety and poor
school performance. Ialongo, Edelsohn, Werthamer-Larsson, Crockett, and Kellam (1995)
9
found that first grade students who suffered from high levels of anxiety symptomatology
were more likely to achieve lower scores for reading and mathematics by the time they
reached Grade 5, as well as experiencing ongoing difficulties with anxiety. More recently, a
longitudinal study of adolescents in New Zealand found that those with anxiety disorders
were more prone to educational underachievement in young adulthood (Woodward &
Fergusson, 2001). The tendency of anxious children to underachieve at school may be in part
due an increased risk of school avoidance, particularly for children with SOP or SAD (Beidel
& Turner, 1988). Accordingly, anxious children may also be more likely to leave school
prior to Grade 12, which may limit future vocational options (Donovan & Spence, 2000;
Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005), further indicating how the impact of
childhood anxiety may continue to resonate over time.
Another aspect of functioning which is compromised by childhood anxiety is that of
social competence, encompassing social skills and self-esteem. It is known that anxious
children are more likely to display a behaviourally inhibited temperament (see Chapter 2:
Risk Factors, for a more comprehensive discussion), typified by shyness, and reticence or
withdrawal in novel situations, which can have a detrimental effect on social development
(Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1994). Broadly speaking,
anxious children are more likely to have social skills deficits. Spence, Donovan, and
Brechman-Toussaint (1999) found that compared to a control group, children with diagnosed
SOP were rated by their parents as less socially skilled. These children typically interacted
less with peers, initiated fewer interactions, and were less likely to receive positive outcomes
from peers during school-based interactions. Socially anxious children are also less likely to
be accepted by their peers (Greco & Morris, 2005), which may increase the risk for more
entrenched internalising behaviour (Ollendick, Weist, Borden, & Greene, 1992; Strauss,
10
Frame, & Forehand, 1987; Strauss, Lahey, Frick, Frame, & Hynd, 1988), and lead to further
interpersonal difficulties and social isolation (Beidel & Turner, 1988; King & Ollendick,
1989; Messer & Beidel, 1994; Pine, 1997). Not surprisingly, children with anxiety are also
more likely to have low self-esteem than their non-anxious peers (Ialongo, Edelsohn,
Werthamer-Larsson, Crockett, & Kellam, 1996; McLoone et al., 2006; Rapee et al., 2005;
Strauss et al., 1987). This may be a risk factor for withdrawal, potentially leading to the
reinforcement and exacerbation of existing anxiety.
In conjunction with the impact on social and academic functioning, the diagnosis of
childhood anxiety confers a significant risk for later psychopathology and poorer functional
outcomes. Both prospective and retrospective studies have demonstrated that childhood
anxiety often precedes anxiety disorders in adulthood (Aronson & Logue, 1987; Lipsitz et al.,
1994; Otto, Pollock, Rosenbaum, Sachs, & Asher, 1994; Pine et al., 1998), and adults with
anxiety disorders who had previously suffered from childhood anxiety may experience more
severe difficulties than anxious adults without a history of childhood anxiety (Otto et al.,
1994). Similarly, anxiety disorders in childhood are predictive of depression in later
adolescence and adulthood (Woodward & Fergusson, 2001). Childhood anxiety has also
been identified as a risk factor for substance abuse (Clark & Winters, 2002; Costello et al.,
2003; McLoone et al., 2006; Rapee et al., 2005; Woodward & Fergusson, 2001), with
research suggesting that some anxiety disorders are more associated with substance use
disorders than others. Clark and Neighbors (1996) note that SOP and PD during adolescence
are linked to substance use disorders, whilst Deykin and Buka (1997) found a lifetime
prevalence rate of 30% for post-traumatic stress disorder (PTSD), in a population of
adolescents with diagnosed drug or alcohol dependence. Other poorer functional outcomes
associated with childhood anxiety include conduct problems, personality psychopathology,
11
and increased use of medical and psychiatric services (Last, Hansen, & Franco, 1997; Rudd
et al., 2004; Weissman et al., 1999).
Summary
This chapter has provided a brief overview of the issue of childhood anxiety. A
review of the literature has revealed that anxiety disorders are the most common category of
childhood psychiatric disorders, with a chronic course that typically extends into adolescence
and adulthood if left untreated. Issues relating to comorbidity were also discussed,
highlighting the increased risk of more entrenched internalising psychopathology in children
with anxiety. The long-term effects of anxiety upon other psychosocial aspects of life have
been shown to be highly detrimental, and associated with such factors as significantly lower
self-esteem, poor social skills, and impaired interpersonal functioning. On a practical level,
anxiety has also been associated with negative outcomes such as educational
underachievement and vocational limitations.
It is irrefutable that anxiety is a significant mental health problem in childhood, both
in terms of direct morbidity, and the associated risks it presents to psychosocial functioning
across the life course. When considered in conjunction with the prevalence rates reported in
the literature, the magnitude of the impact of childhood anxiety at a macro level is especially
concerning, and highlights the real need for effective and timely intervention strategies.
The effectiveness of interventions for anxiety in children relies heavily on a thorough
understanding of the risk factors implicated in the development of childhood anxiety, and
how these may predispose some individuals to the development of the disorder. This
knowledge is complimented by an understanding of protective factors which may buffer the
12
child against risk factors for anxiety, and an understanding of how these can be built upon
and enhanced through strategic interventions. The following chapter reviews the literature
regarding risk and protective factors for childhood anxiety.
13
CHAPTER TWO: RISK & PROTECTIVE FACTORS FOR CHILDHOOD ANXIETY
In considering the aetiology of anxiety, it is important to recognise the role that risk
and protective factors play in the likelihood of developing an anxiety disorder in childhood.
A better understanding of these factors more fully informs intervention strategies and
preventative programs. The following chapter reviews a range of both risk and protective
factors that are heavily implicated in childhood anxiety.
Risk Factors for Childhood Anxiety
Research into the aetiology of childhood anxiety disorders has yielded a number of
variables which are heavily associated with the presence of a disorder. The presence of these
variables, or risk factors, may predict the onset, severity, and duration of the disorder (Coie et
al., 1993). Risk factors can include variables specific to the individual, or those that operate
more broadly across a cultural level. Several categories of risk factors for anxiety have been
identified, including biological, psychological, and environmental (Donovan & Spence,
2000). Whilst strong correlations between anxiety and a range of risk factors have been
identified, these relationships are complex, and not necessarily causal. Risk factors are
dynamic, and their presence may fluctuate over time. In some cases, anxiety may precede the
presence of significant risk factors (Donovan & Spence, 2000). Furthermore, the effect of
risk factors may be developmentally sensitive, and their influence may vary depending on the
developmental stage of the individual (Coie et al., 1993; Mrazek & Haggerty, 1994). Whilst
the presence of risk factors does not always precipitate the development of anxiety, a higher
number of risk factors generally increases vulnerability, and may predict a more severe
illness course (Coie et al., 1993; Mrazek & Haggerty, 1994). This section discusses anxiety
risk factors across each of the three categories mentioned above. It will commence with a
14
discussion of biological risk factors, followed by psychological factors, and conclude with
environmental risk factors.
Biological Factors
Biological risk factors for anxiety are those which are thought to be innate from birth,
or inherited. One such factor is temperament, which is theorised to have a genetic component
(Donovan & Spence, 2000). Individuals with certain temperament characteristics are at an
increased risk for the development of anxiety disorders, and the temperament style that is
arguably most strongly associated with anxiety is behavioural inhibition (Biederman et al.,
1993; DiLalla, Kagan, & Reznick, 1994; Kagan, 1997; Kagan, Reznick, & Gibbons, 1989;
Kagan, Snidman, Zentner, & Peterson, 1999; Rosenbaum et al., 1993). The role of
behavioural inhibition as a risk factor for anxiety is discussed below.
Behavioural inhibition. Behavioural inhibition, which occurs in approximately 15%
of children (Asendorpf, 1990; Hirschfeld-Becker et al., 2008; Kagan, 1997) is manifested by
timidness, shyness, and avoidance behaviours in novel contexts, and increased physiological
arousal in response to these contexts (Biederman et al., 1993; Hirschfeld-Becker et al., 2008).
As behavioural inhibition is a coping mechanism which reduces fear and anxiety, the
behaviours of inhibited children become further entrenched through reinforcement, which can
lead to more severe anxiety difficulties and other psychopathology in the future (Biederman,
Hirschfeld-Becker et al., 2001; Gar, Hudson, & Rapee, 2005; Gladstone & Parker, 2006;
Gladstone, Parker, Mitchell, Wilhelm, & Mahli, 2005; Kagan et al., 1999; Rosenbaum et al.,
1991; Schofield, Coles, & Gibb, 2009).
15
Pioneering research in the area of behavioural inhibition was conducted by Kagan and
colleagues (Garcia-Coll, Kagan, & Reznick, 1984; Kagan et al., 1989; Kagan, Reznick,
Clarke, Snidman, & Garcia-Coll, 1984; Kagan, Reznick, & Snidman, 1987; Kagan, Reznick,
Snidman, Gibbons, & Johnson, 1988), who assessed behavioural inhibition in two groups of
infants (aged 21 months and 31 months at the outset) over a 6-year period. The children were
exposed to novel stimuli, including unfamiliar situations, people, and objects, in a laboratory
setting, and their behaviours were observed by researchers. Those children who displayed a
behaviourally inhibited temperament were significantly more likely to be fearful of the novel
stimuli and to demonstrate avoidance behaviours. By comparison, children with an
uninhibited temperament were significantly less distressed by the novel stimuli, being more
likely to engage in social and spontaneous behaviours. Importantly though, behavioural
inhibition did not remain stable for all children over time. It was found that only infants who
were extremely behaviourally inhibited were more likely to remain so into childhood,
whereas those infants who were found to be extremely uninhibited were more likely to
remain uninhibited into childhood (Kagan et al., 1989). These findings indicate that
behavioural inhibition, particularly at this extreme end of the scale, may be a distinct
vulnerability for later difficulties with anxiety.
Later research by Biederman et al. (1990) revealed a link between behavioural
inhibition and childhood anxiety disorders. The study investigated behavioural inhibition and
psychopathology in children of parents with PD and agoraphobia, and children of parents
with other psychiatric disorders. It was found that the children of parents with PD and
agoraphobia were significantly more likely to be identified as behaviourally inhibited than
children of parents with other disorders. Furthermore, children in the behaviourally inhibited
group were also more likely to meet diagnostic criteria for an anxiety disorder, than children
16
in the uninhibited group. Biederman et al. (1990) also investigated rates of psychopathology
in the original sample examined by Garcia-Coll et al. (1984); whilst children who had been
identified as behaviourally inhibited infants were more likely to meet criteria for an anxiety
disorder, the difference in rates of disorders between the two dichotomised groups was not
significant. By comparison, results from a three-year follow-up of Biederman et al.'s (1990)
original sample demonstrated that children identified as behaviourally inhibited were
significantly more likely to meet diagnostic criteria for avoidant disorder (now known under
the diagnosis of SOP), SAD, and agoraphobia, than uninhibited children (Biederman et al.,
1993).
More recent research with the original sample has also supported the above findings.
Longitudinal research by Kagan et al. (1999) investigated the link between behaviours
associated with behavioural inhibition in 164 infants aged 4 months, and anxiety symptoms in
later childhood. It was found that infants identified as highly reactive were more likely to
display anxious symptomatology as 7-year-olds, based on parent-report measures. Despite
this finding, it is important to note that of those infants originally identified as highly
reactive, fewer than 10% went on to develop anxiety symptoms by age 7. Similarly, recent
longitudinal research by Hirschfeld-Becker et al. (2007) found that whilst behaviourally
inhibited temperament in preschool-aged children constituted a significant risk for social
anxiety five years later, most children with early behavioural inhibition did not go on to
develop significant anxiety difficulties in middle childhood. This finding indicates that the
relationship between behavioural inhibition and anxiety disorders is by no means causal, but
is likely mediated by several other factors.
17
Whilst much of research in this field has been concerned with several key cohorts,
suggesting caution in interpretation of results, similar findings have resulted from research
with different data sets. One such example is a large scale longitudinal study of Australian
children, with data collected at eight time points from infancy to early adolescence (Prior,
Smart, Sanson, & Oberklaid, 2000). Prospectively, inhibited temperament during infancy
was associated with anxiety problems in later childhood. This relationship was strongest for
children rated as inhibited on at least six of the eight assessment occasions, with 42%
experiencing anxiety difficulties based on parent report measures. Retrospectively however,
47% of children with parent-reported anxiety difficulties in adolescence had either rarely or
never been identified as inhibited across the duration of the study. Again, this research
suggests that whilst behavioural inhibition is implicated in the development of anxiety
disorders in later childhood, the relationship between the two is likely influenced by a
complex interplay of other factors.
It is worth drawing attention here to methodological difference between studies
investigating the relationship between behavioural inhibition and anxiety disorders in
children. Whilst research reviewed to date has produced findings based on longitudinal data
collected from parent report measures (Hirschfeld-Becker et al., 2007; Kagan et al., 1989;
Kagan et al., 1988; Kagan et al., 1999; Prior et al., 2000), other researchers have established
this link using adult participants’ retrospective reports of their own functioning as children
(Gladstone et al., 2005; Reznick, Hegeman, Kaufman, Woods, & Jacobs, 1992; Schofield et
al., 2009). Gladstone et al. (2005) gathered data from both retrospective reports of childhood
inhibition and a measure of adult behavioural inhibition from 189 adults, aged between 17
and 68 years. Participants were also assessed for anxiety and depression using structured
diagnostic interviews. Participants were classified into either the “low”, “medium”, or “high”
18
inhibition group, based on both retrospective and current measures of behavioural inhibition.
Significant between-group differences were noted with regard to anxiety disorder diagnoses.
Specifically, participants in the high retrospective inhibition group were more likely to meet
criteria for SOP or SP, and were also more likely to have experienced multiple anxiety
disorders. This research therefore successfully used retrospective reports to further establish
behavioural inhibition as a risk factor for anxiety.
Most recently, another retrospective study by Schofield et al. (2009) examined links
between behavioural inhibition in early childhood, and symptoms of social anxiety,
depression and anxious arousal in young adults. Two hundred and forty-seven undergraduate
students completed self-report measures on retrospective behavioural inhibition, and anxious
and depressive symptomatology. Consistent with the earlier study (Gladstone et al., 2005),
retrospective reports of behavioural inhibition during early childhood were significantly
linked to social anxiety and anxious arousal symptoms in young adulthood. More
specifically, and as predicted, the social component of behavioural inhibition (typified by
reticence to interact with strangers) was more strongly associated with social anxiety than
with the non-social component of behavioural inhibition (characterised by reluctance to
explore unfamiliar surroundings, and fearful responses when exposed to potentially
threatening situations). Another interesting finding was that retrospective reports of
behavioural inhibition were also associated with depressive symptomatology, and the
relationship between these two was mediated by anxiety. These findings, consistent with
earlier research (Gladstone & Parker, 2006), suggest that not only are inhibited children at
greater risk of developing both anxiety and depressive disorders in later life, but that anxiety
is heavily implicated in the later development of depressive disorders in children identified as
behaviourally inhibited.
19
The research reviewed above provides considerable evidence for the predictive utility
of behavioural inhibition as a risk factor for anxiety not only in childhood, but well into
adolescence and adulthood as well. The relationship between behavioural inhibition and
anxiety has been established using both longitudinal data (Hirschfeld-Becker et al., 2007;
Kagan et al., 1989; Kagan et al., 1988; Kagan et al., 1999; Prior et al., 2000) and
retrospective reports of childhood inhibited behaviour (Gladstone et al., 2005; Reznick et al.,
1992; Schofield et al., 2009). The fact that this relationship has been demonstrated
successfully using two differing methodologies signifies that the relationship between the two
factors is robust, and may therefore be very useful in a clinical setting.
Psychological Factors
Research into correlates of anxiety disorders in children has revealed several
cognitive factors that are associated with childhood anxiety (Craig & Dobson, 1995; Muris &
Field, 2008; Prins, 2001). Such cognitive factors are linked to the tendency of anxious
children to disproportionately attend to threat, overestimate threat, underestimate their own
personal coping and social skills (Cartwright-Hatton, Tschernitz, & Gomersall, 2005) and
experience distorted and maladaptive cognitions (Craig & Dobson, 1995; Silverman &
Treffers, 2001). The link between cognition and anxiety has been explained by cognitive
theory, whereby schemas of danger result in prioritised processing of threatening information
and erroneous processing of ambiguous situations, leading to cognitive distortions and
apprehensive behaviours which reinforce anxiety (Kendall, 1985). The literature in this field
is extensive, and it is not viable to discuss all cognitive factors linked to anxiety here. As
such, this section will review evidence for two of the most empirically supported variables:
20
attention bias and interpretation bias, each of which will be discussed in the context of
childhood anxiety disorders below.
Attention bias. Significant links have been identified between attention bias and
anxiety disorders, with evidence suggesting this factor may be fundamental in the
development and maintenance of clinical anxiety (Bar-Haim, Lamy, Pergamin, Bakermans-
Kranenburg, & van Yzendoorn, 2007; Muris & Field, 2008). A recent meta-analysis of
attention bias research demonstrated that attention is disproportionately allocated to
threatening stimuli by clinically anxious and highly anxious individuals (Bar-Haim et al.,
2007). This has been consistently found with adults, whereby anxious individuals show clear
attention biases to threatening stimuli, and are more likely to interpret threat in ambiguous
situations (Williams, Matthews, & MacLeod, 1996). This disproportional attention to threat
is generally not seen in non-anxiety disordered adults, and is significantly less common in
adults with sub-clinical levels of anxiety. Accordingly, attention bias is hypothesised to play
a significant role in the development and maintenance of anxiety disorders. Following from
the wealth of literature on attention biases in anxious adults, researchers have sought to
determine whether anxious children also demonstrate an attention bias towards threat. The
body of literature on attention bias to threat in children and adolescents is relatively small,
compared to that of other risk factors for anxiety, and results have been less conclusive than
those from research with adults. The following section will review the literature in this area
to date.
Early research into the link between attention bias and childhood anxiety disorders
was conducted by Vasey, Daleiden, Williams, and Brown (1995), who compared the
performance of 12 children diagnosed with an anxiety disorder and 12 non-disordered
21
children (aged 9 to 14 years) on a dot-probe detection task. The task was designed to
measure the direction of visual attention in response to emotionally threatening and neutral
words. Participants viewed word pairs on a screen; some pairs consisting of two neutral
words, whilst other pairs consisted of one emotionally threatening word (e.g. Accident) and
one neutral word (e.g. Apple). Following display of word pairs, a dot probe appeared on the
screen, and participants were required to press a button upon noticing the probe. It was found
that anxious children responded significantly faster to the appearance of probes following
threatening words than to probes following neutral words. By comparison, there was no
difference between the response-latencies of non-disordered children for probes following
either threatening or neutral words. These results were later replicated with a non-clinical
group of 40 children aged 12 to 14 years, who had been identified as having either high text
anxiety or low test anxiety (Vasey, El-Hag, & Daleiden, 1996). Consistent with the earlier
research (Vasey et al., 1995), the more anxious children displayed significantly faster
response-latencies to probes following threatening words. These findings were interpreted as
evidence of an attention bias towards threat in clinically and sub-clinically anxious children,
which is consistent with research conducted with adults (Bar-Haim et al., 2007; Williams et
al., 1996).
Later research also demonstrated evidence for attention bias to threat in both anxious
and non-clinically diagnosed children and adolescents. Taghavi, Dalgleish, Moradi, Neshat-
Doost, and Yule (2003) found that children and adolescents with GAD disproportionately
attended not only to threatening stimuli but also to depression-related stimuli. Similarly,
research with a non-clinical sample of youths aged between 9 and 17 years revealed that
more severe child-rated anxiety symptomatology was associated with attention bias to
threatening words and images (Watts & Weems, 2006). Later, Waters, Mogg, Bradley, and
22
Pine (2008) investigated attention bias for emotional human faces in children aged 7 to 12
years. Children diagnosed with GAD (n=23) and a non-anxious control group (n=25)
completed a dot-probe task involving pairs of photographs of human faces on a computer,
with neutral-neutral, neutral-angry, or neutral-happy expression combinations. A relationship
between response latency and anxiety was found only for children with high clinical anxiety
from the GAD group, whereby these children were significantly quicker to respond to probes
presented after angry faces. Children with low clinical anxiety from the GAD group did not
differ in terms of their visual attention to angry, happy or neutral faces. The above-reviewed
literature suggests that attention bias to threat is significantly associated with more severe
anxiety in children from both clinical and community samples.
Most recently, innovative research by Legerstee et al. (2009) extended the
understanding of links between attention bias and childhood anxiety, via demonstrating that
attention bias to threat is also predictive of outcome in interventions for childhood anxiety.
The study involved 131 children aged 8 to 16 years with a diagnosable anxiety disorder.
Prior to commencing a CBT intervention for anxiety, all children participated in a pictorial
dot-probe task to assess selective attention. The task involved presentation of image pairs in
three different combinations: severely threatening/neutral, mildly threatening/neutral, and
neutral/neutral. Participants were asked to respond as quickly as possible to the presentation
of a dot probe immediately after the display of each image pair. Following the completion of
the intervention program, significant differences were noted between participants who
responded to treatment (i.e. were diagnosis free at post-treatment), and those who failed to
respond. Specifically, children who responded to treatment showed a selective attention
away from the severely threatening stimuli in the dot probe task, whereas children who failed
to respond typically displayed selective attention towards severe threat. This finding has
23
important ramifications for the field of anxiety intervention and prevention, indicating that
additional attention training components may be required for some children to make positive
gains from these types of interventions (Legerstee et al., 2009). Furthermore, it may also
indicate that children with attention bias towards threat are at greater risk of relapsing post-
treatment.
In contrast to the above reviewed literature, several researchers have failed to find
significant links between attention biases and anxiety in children. Kindt, Bierman, and
Brosschot (1997) sought to compare attention bias for spider words in children with self-
reported spider fears and control children. The study employed a Stroop task methodology,
and included four word sets: (1) incongruent colour words, (2) non-words, (3) spider words,
and (4) control words. It was found that colour-naming latencies were significantly greater
for spider words than for control words, in children both with spider and without identified
spider fears, indicating that all children demonstrated a stronger processing bias for spider
words. Other research employing the Stroop task methodology also failed to differentiate
between anxious and non-anxious children in terms of their attention bias to fearful medical
situations (Kindt, Brosschot, & Everaerd, 1997), and pictorial and linguistic spider stimuli
(Kindt & Brosschot, 1999). Similar results have been found in research employing the dot-
probe task methodology, with no significant differences in the response-latencies of clinically
anxious and non-disordered children (Waters, Lipp, & Spence, 2004).
One explanation for the discrepancy in the literature on the link between attention bias
and childhood anxiety disorders pertains to the age of the children examined. Research has
found that younger children aged between 8 and 12 years are more likely to demonstrate a
general bias for fear-related stimuli (Kindt, Bierman et al., 1997; Kindt, Brosschot et al.,
24
1997), whilst anxiety-specific biases are typically found in older children and adolescents,
aged 9 to 19 years (Moradi, Taghavi, Neshat-Doost, Yule, & Dalgleish, 1999; Taghavi et al.,
2003; Taghavi, Neshat-Doost, Moradi, Yule, & Dalgleish, 1999; Vasey et al., 1995; Vasey et
al., 1996; Vasey & MacLeod, 2001). In explanation, it has been argued that young children
do not possess the cognitive capacity to avoid processing fearful stimuli. With regards to
older children however, non-anxious individuals may inhibit selective attention to anxiety-
provoking stimuli, whereas anxious individuals do not possess this capability (Kindt,
Bierman et al., 1997). Regardless of variability in results, the available literature suggests
that attention bias does have a role to play in the development of anxiety in children, and that
this effect may be mediated or moderated by other factors.
Interpretation bias. Interpretation bias is used to describe the tendency of anxious
individuals to interpret threat in an ambiguous situation (Muris & Field, 2008). Situations
interpreted as threatening or dangerous can elicit typical anxiety responses such as
physiological arousal and avoidance behaviours, which serve to reinforce anxious cognitions
and maladaptive coping strategies (Muris & Field, 2008). Evidence of interpretation bias in
anxious children has been found by a number of researchers. Hadwin, Frost, French, and
Richards (1997) used a self-report measure of trait anxiety with 40 children aged 7 or 9 years,
who were then asked to listen to a set of homophones (words with two separate meanings)
played on a tape. Participants were then shown a card with two pictorial depictions of the
homophones, one neutral and one threatening (e.g. Bark – tree, and Bark - dog), and were
asked to point to the picture which represented the word they had heard. A significant
positive correlation was found between anxiety levels and threatening interpretations,
whereby children with higher levels of self-reported anxiety were more likely to interpret
homophones as threatening. In later research Taghavi, Moradi, Neshat-Doost, Yule, and
25
Dalgleish (2000) found that anxious children were more likely than non-disordered control
children to select threatening homograph interpretations over neutral interpretations, in the
construction of sentences.
Whilst anxious children have been shown to interpret ambiguous stimuli such as
words and images as threatening, this effect has also been demonstrated in response to
potential real-life situations. Barrett, Rapee et al., (1996) compared interpretation biases in
anxiety-disordered children aged between 7 and 14 years, with children diagnosed with ODD,
and non-disordered controls. Participants were exposed to brief vignettes of ambiguous
situations and asked to interpret each. They were then presented with two potential neutral
outcomes and two potential threatening outcomes, and asked to select which was the most
likely outcome for each given situation. It was found that anxious and oppositional-defiant
children were significantly more likely to assign threat to ambiguous situations, and anxious
children were more likely to select an avoidant outcome to the situation, compared to the
other two groups. These results were also found in later research by Bögels and Zigterman
(2000), who investigated interpretation bias in three groups of children diagnosed with an
anxiety disorder (SOP, SAD, or GAD) compared to a normal control group. When
confronted with a range of scenarios, anxious children were significantly more likely to
report negative cognitions, judge the situations as dangerous, and to provide lower estimates
of their competency to cope with the dangers, compared to non-disordered children.
More recently, Dineen and Hadwin (2004) have investigated whether children with
anxious and depressive symptomatology differ in terms of interpretation bias. In this study,
29 children aged 7 to 9 years were exposed to a series of scenarios of children interacting in a
social setting. Scenarios were classified as positive (e.g., child holding a present for another
26
child at a party), negative (e.g., child pushing over another child to win a race), or ambiguous
(e.g., child knocking over another child’s bricks) in nature. Following this, participants were
asked to judge how the protagonist (other judgement) and how they themselves (self-
judgement) would interpret the intentions of the second child in each scenario. It was found
that whilst depressive symptomatology was associated with greater negative self-judgement
interpretations, anxiety was predictive of an increase in negative interpretations of others.
This finding reflects previous literature which indicating that anxious children demonstrate an
interpretation bias towards threat in ambiguous situations.
Another form of interpretation bias has been referred to as the reduced evidence for
danger (RED) bias, which refers to the speed with which anxious children interpret threat in
ambiguous situations (Muris, Rapee, Meesters, Schouten, & Geers, 2003). This bias is
generally demonstrated through the use of ambiguous vignettes; children are informed that
some will be scary, and some will be happy, and their task is to identify as quickly as possible
which vignettes fit each category. As the vignettes are presented sentence by sentence,
children have an opportunity to identify the vignette as scary or happy at the end of each
sentence. This methodology was used by Muris, Merckelbach, and Damama (2000) with a
sample of sub-clinical socially anxious children aged 8 to 13 years. It was found that
children with higher levels of social anxiety needed to hear fewer sentences before labelling a
story as scary. This finding was taken as evidence of a RED bias, whereby anxious children
require less information before interpreting threat in a given situation.
The literature reviewed above has established that both attention bias and
interpretation bias are significant risk factors for anxiety. With regard to the former, research
involving both clinically anxious children and sub-clinical populations has demonstrated that
27
anxiety symptomatology is strongly associated with attentional biases towards threatening
stimuli. The fact that this finding has been robust across the spectrum of anxiety severity
suggests that attention bias towards threat may be an important risk factor for the
development and maintenance of childhood anxiety. Similarly, the available literature on
interpretation bias quite clearly implicates interpretation of threat and danger in ambiguous
situations as a risk factor for anxiety. Persistent maladaptive interpretation may promote and
reinforce avoidance, and in turn, contribute to clinical anxiety in children. The understanding
of how these risk factors are related to anxiety may be used in the development of
intervention strategies which more effectively target these cognitive biases, thereby reducing
anxiety.
Environmental Factors
The environment within which a child functions has been shown to play a role in the
development of childhood anxiety. Environmental factors include those inside the home
environment, such as parental psychopathology, parenting behaviours, and the quality of
attachment between parent and child, as well as traumatic or stressful events and contexts that
the child may be exposed to in the course of everyday life. For the purpose of this section,
empirical evidence for a selection of environmental factors linked to childhood anxiety will
be reviewed, focusing primarily on parent variables and exposure to traumatic events.
Parental psychopathology. There is a strong link between childhood anxiety and
parental psychopathology (Last, Hersen, Kazdin, Greta, & Grubb, 1987; Mesman & Koot,
2000; Rosenbaum et al., 1988; Turner, Beidel, & Costello, 1987; Weissman, Leckman,
Merikangas, Gammon, & Prusoff, 1984). Research has demonstrated that children of anxious
parents are between two to seven times more likely to develop an anxiety disorder than
28
children of non-anxious parents (Capps, Sigman, Sena, Henker, & Whalen, 1996; Turner et
al., 1987) with children of depressed parents also at an increased risk of developing anxiety
disorders (Beidel & Turner, 1997; Kovacs et al., 1989). Both maternal psychopathology
(Leve, Kim, & Pears, 2005) and paternal psychopathology (Compas, Phares, Banez, &
Howell, 1991; Kane & Garber, 2009) significantly predict anxiety disorders in children.
Additionally, parents of children diagnosed with anxiety disorders are also significantly more
likely to report anxiety and depressive symptomatology than parents of non-disordered
children (Suveg, Zeman, Flannery-Schroeder, & Cassano, 2005).
Early research by Turner et al. (1987) investigated anxiety in children of anxious
parents, dysthymic parents, and parents without psychiatric diagnoses. Children of anxious
parents were twice as likely to be at risk for developing an anxiety disorder, compared to
children of dysthymic parents, and seven times more at risk than children of parents without
psychiatric diagnoses. In conjunction with this increased risk, children of anxious parents
were more likely to report that they had experienced difficulties at school, that they spent
more time worrying, and that they were more socially isolated than children of parents
without a diagnosis. A similar study investigated the prevalence of psychiatric disorders in
81 children of parents with a diagnosis of either anxiety, depression, or comorbid anxiety and
depression, versus children of parents free from psychiatric diagnoses (Beidel & Turner,
1997). Building on results from the earlier research, it was found that children of parents with
either diagnosable anxiety, depression, or comorbid anxiety and depression, were more likely
to fulfil criteria for a psychiatric disorder themselves, compared to children of parents who
were diagnosis free. For children of anxious parents, anxiety disorders were particularly
more common than any other type of disorder.
29
More recent research has focused on the longitudinal link between parental
psychopathology and anxiety in children. In a population-based study of 2230 children aged
10 to 11 years, lifetime parental psychopathology (depression, anxiety, substance
dependence, antisocial behaviour, and psychosis) was assessed through parent interview, and
child psychopathology was assessed via parental, child, and teacher self-report measures
(Ormel et al., 2005). At 2.5 years follow-up, lifetime parental internalising (anxiety and
depression) psychopathology significantly predicted internalising problems in children.
Another more recent longitudinal study investigated early childhood risk factors for anxiety
in preadolescence (Ashford, Smit, van Lier, Cuijpers, & Koot, 2008). Internalising problems
in 294 children were assessed by parent report at age 2-3 years, and by both parent and
teacher report at 4-5 years and 11 years. Risk indicators were also assessed, including
parental psychopathology, child health, single parenthood, life events, parenting stress, and
socioeconomic status. Parental psychopathology at age 2-3 years was found to be one of the
strongest predictors of internalising problems in children at the age of 11. Both these studies
indicate the longitudinal effects of parental psychopathology on the development of
childhood anxiety, with the later study demonstrating its predictive significance as a risk
factor in children as young as 2 to 3 years of age.
Following from the robust evidence that parental psychopathology and childhood
anxiety are linked, some researchers have investigated familial effects of specific anxiety
disorders. Biederman, Faraone et al. (2001) compared anxiety in children of parents with PD
on its own, and when comorbid with depression. Four groups of children and their parents
were investigated: (1) Children of parents with PD and comorbid depression (n = 179), (2)
children of parents with PD without comorbid depression (n = 29), (3) children of parents
with depression only (n = 59), and (4) children of parents with no psychiatric diagnosis (n =
30
113). As predicted, children of parents with PD, depression, or comorbid PD and depression
were significantly more likely to suffer from multiple anxiety disorder themselves, as
compared to children of parents without psychiatric diagnoses. Children of parents with PD,
regardless of comorbidity with depression, were significantly more likely to themselves meet
diagnostic criteria for PD and agoraphobia than the control group. By comparison, children
of parents with depression, regardless of comorbidity with PD, were more likely to meet
diagnostic criteria for SOP, SAD, and depression. The increased risk for PD in children of
parents who themselves suffer from PD suggest that vulnerabilities for specific anxiety
disorders may be transmitted intergenerationally.
Empirical research clearly demonstrates strong evidence that children of parents with
psychopathology are at an increased risk of childhood anxiety disorders. It is important to
note that the relationship between parental psychopathology and childhood anxiety is not
causal, but may be mediated through other genetic and environmental mechanisms (Donovan
& Spence, 2000). With regards to the latter, parenting behaviour is one risk factor that has
been posited as a variable in the relationship between parental psychopathology and
childhood anxiety. Parenting behaviour as a risk factor for childhood anxiety will be
discussed below.
Parenting behaviour. Empirical evidence suggests that some parenting behaviours
are associated with an increased risk of childhood anxiety disorders (Donovan & Spence,
2000). Parents of anxious children may encourage and maintain their child’s anxiety through
modelling their own anxious behaviours, attributional styles, and negative cognitions, and
through reinforcing anxious and avoidant behaviours (Bayer, Sanson, & Hemphill, 2006;
Fisak & Grills-Taquechel, 2007; Rapee & Szollos, 2002). Despite the strong correlation
31
between parental psychopathology and childhood anxiety discussed in the previous section,
the differential effects of biology and environment make the developmental pathway of
childhood anxiety a complex one. With regards to the latter however, research to date has
highlighted differences between the practices of parents of anxious and non-anxious children.
A selection of this research will be discussed below.
In examining the relationship between parenting practices and childhood anxiety,
Barrett, Rapee et al. (1996) investigated differences in threat interpretation bias in anxious,
oppositional, and non-disordered children by asking them to interpret and provide plans of
action for ambiguous scenarios (plans were coded as either pro-social, avoidant, or
aggressive). Following this, children participated in a 5 minute family discussion with their
parents to help them determine a final plan of action. It was found that anxious children and
their parents were more likely to interpret ambiguous situations as threatening. Anxious
children were also significantly more likely to choose an avoidant response prior to the
family discussion, compared to oppositional and non-disordered children. Perhaps the most
notable finding however was that significant numbers of anxious children changed from a
pro-social response to an avoidant response, following the family discussion. It was also
noted that children from the oppositional group were more likely to change to more
aggressive responses following family discussion. Barrett, Rapee et al. (1996) termed this the
FEAR effect - Family Enhancement of Avoidant and Aggressive Responses, demonstrating
the role that parenting behaviours play in the anxiety of children.
A later investigation of the FEAR effect was conducted by Shortt, Barrett, Dadds, and
Fox (2001). One hundred and forty-seven children (aged 6 to 14 years) and their parents
were exposed to seven ambiguous situations; both parents and children were asked how they
32
would interpret the situation, and parents were also asked how they thought their child would
behave if they were in the given situation. Following this, the child and their parents engaged
in a family discussion about what action the child would take if they were exposed to the
situation. It was found that anxious children were more likely to interpret threat in the
ambiguous situations than non-disordered children, and more likely to endorse more avoidant
response plans than children with externalising disorders and non-disordered children.
Consistent with earlier research (Barrett, Rapee et al., 1996), both anxious children and
children with externalising disorders were significantly more likely to change their pro-social
responses to avoidant and aggressive responses respectively. Interestingly, children within
the anxious group were equally as likely to change to an avoidant response whether they
presented their response with their parents, or alone in a separate room from their parents.
This finding suggesting the FEAR effect is the stronger than the tendency of anxious children
to be compliant and eager to please. Clearly, this research presents further evidence
supporting the notion that some parenting behaviours may encourage anxious and avoidant
behaviour in children.
More recent research has further examined how parents may unknowingly reinforce
anxiety through supporting or rewarding their child’s anxious and avoidant behaviours.
Barrett, Fox, and Farrell (2005) compared parent-child interactions in three different groups:
anxious children, similar-aged siblings of the anxious children, and a non-clinical control
group of children. For task one, each parent-child dyad was required to engage in a
discussion about how the child should interpret and respond to an ambiguous social situation.
For task two, parents initiated discussion with their child about a topic they had identified that
would cause their child to feel anxious. Observations of the interactions revealed that
mothers of anxious children showed more anxious parenting behaviours, such as focusing on
33
negatives, and doubting in the success of their child, than parents of children in the non-
clinical control group. Parents of anxious children exhibited the same parenting behaviours
during interactions with their non-anxious children, suggesting that their anxious parenting
behaviours were consistent across members of the family, rather than concentrated on the
anxious child.
In conjunction with the more direct influence of parenting behaviour and practices,
parents may also influence their child’s anxiety more indirectly via modelling of anxious
behaviour, particularly if the parents themselves suffer from clinical anxiety. The link
between parent modelling of anxious behaviour and childhood anxiety was aptly
demonstrated in research by Muris et al. (1996). Forty clinic-referred children (aged 9 to 12
years) and their parents completed self-report measures of state and trait anxiety, and fear.
For parents, an additional item was added to the fear measure, asking them to rate to what
degree they expressed fear in front of their children by selecting one of three options: 'almost
never', 'sometimes', or 'often’. A significant positive correlation was found between trait
anxiety in children, and trait anxiety in both mothers and fathers, a finding that further
demonstrates the link between parental and child anxiety. Additionally, self-reported
fearfulness in children was significantly correlated with self-reported fearfulness in mothers.
Of particular note, however, was a significant positive association between children’s self-
reported fearfulness, and mothers’ ratings of their own expressions of fear in front of their
children. More specifically, children of mothers who reported “always” expressing fears in
front of their children reported the highest fearfulness, whereas children of mothers who
reported “never” expressing fears in front of their children reported the lowest fearfulness.
This finding suggests that children of mothers who express fears more overtly are at greater
34
risk for experiencing anxiety and fear, through modelling the observed anxious behaviour
themselves.
The influence of parental modelling on childhood anxiety has been identified not only
via parental self-report of their anxious behaviours, but also from children’s perceptions of
their parents’ behaviours. Early research by Bruch, Heimburg, Berger, and Collins (1989)
analysed retrospective ratings of anxious behaviour in parents of individuals diagnosed with
SOP and agoraphobia. Those with SOP were more likely to report that their mothers were
avoidant, placed greater emphasis on the opinions of others, and isolated them as children, a
finding which has since been replicated (Bruch & Heimburg, 1994; Caster, Inderbitzen, &
Hope, 1999). Later, Muris and Merckelbach (1998) investigated links between child-reported
anxiety symptomatology and perceptions of parental rearing behaviours in a sample of non-
disordered children aged 8 to 12 years. Results indicated that anxious rearing behaviours
were positively correlated with child self-reported anxiety symptomatology, whereby
children who perceived their parents’ behaviours as anxious were themselves more likely to
report higher levels of anxiety symptoms. These findings were supported by later research
indicating that child perceptions of anxious behaviours in parents were associated with
greater self-reported worry in children (Muris, Meesters, Merckelbach, & Hulsenbeck, 2000).
Research to date supports the hypothesis of parental modelling as a contributing factor
to childhood anxiety disorders. It appears that some parents, particularly those with anxiety
disorders, may contribute to the anxiety of their offspring through expressing their own
anxious thoughts and demonstrating their own anxious and avoidant behaviours in front of
their children.
35
Attachment style. The quality of the attachment between child and parent is a
significant factor in the development of childhood anxiety disorders (Erickson, Sroufe, &
Egeland, 1985; Main, 1996; Sroufe, Egeland, & Kreutzer, 1990), with poor parent-child
relationships a recognised risk factor for childhood anxiety (Barrett, Fox, et al., 2005).
Attachment relates to the child’s sense of security and safety. Children are motivated to seek
proximity to an attachment figure in times of uncertainty or stress; if the attachment figure is
unavailable or unresponsive, anxiety increases in response to the experience of uncertainty,
threat, or danger (Bowlby, 1988). A secure parent-child attachment is characterised by
warm, emotionally sensitive and responsive parenting behaviours, allowing the child to be
comforted and soothed, whilst contributing to the development of self through providing a
secure base from which children feels safe to explore their world (Ainsworth, Blehar, Waters,
& Wall, 1978; Bowlby, 1988; Sroufe, 1996). By contrast, insecure attachment patterns such
as ambivalent attachment (characterised by heightened display of negative emotions when
seeking attention of the attachment figure) and avoidant attachment (characterised by a lack
of distress at the unavailability of the attachment figure) are typically related to unresponsive,
hostile, or rejecting parenting behaviours. This may lead to deficits in cognitive and
emotional coping strategies (Carlson & Sroufe, 1995; Svanberg, 1998; Sroufe, 1996), which
potentially increases the risk of later psychopathology.
There is evidence to indicate that insecure attachment is associated with many
unfavourable developmental outcomes, including clinical anxiety and other forms of
psychopathology (Main, 1996). Longitudinal research by Bosquet and Egeland (2006)
investigated factors implicated in the aetiology and course of anxiety in 155 children
followed from infancy through to adolescence. Quality of attachment between parent and
child was assessed when participants were 12 and 18 months of age. Children with insecure
36
attachment identified in infancy were significantly more likely to experience emotion
regulation difficulties by the time they reached preschool, and these difficulties were linked
to the development of anxiety symptoms in middle childhood. By the time the participants
reached preadolescence, those who experienced an insecure attachment in infancy were also
more likely to have difficulties with peer relationships, which was associated with increased
anxiety in adolescence. Further research by Roelofs, Meesters, Huurne, Bamelis, and Muris
(2006) investigated self-reported anxiety symptomatology in children aged 9 to 12 years.
Those with insecure attachments reported greater anxiety than those with secure attachments.
Whilst these studies did not differentiate between ambivalent and avoidant attachment styles,
they provide convincing evidence that insecure attachment in general may result in an
increased risk for anxiety in later childhood.
Given that the characteristics of avoidant and ambivalent attachment vary somewhat,
some researchers have argued that one pattern might be the more reliable pathway to
childhood anxiety than the other. The argument for the former is based on the fact that
parents of avoidant children may ignore or reject their children, and fail to comfort them
when in distress. In this way, avoidant children may learn to avoid displaying negative affect
to ensure their emotional needs are met (Bradley, 2000; Goldberg, MacKay-Soroka, &
Rochester, 1994), resulting in maladaptive emotional coping. Several studies support this
argument, with avoidantly attached children demonstrating elevated internalising symptoms
in comparison to ambivalently attached (Goldberg, Gotowiec, & Simmons, 1995) and
securely attached children (Lyons-Ruth, Easterbrooks, & Cibelli, 1997). Despite these
findings, it is important to note that anxiety symptoms were not specifically distinguished
from the broader internalising symptom variable for the purpose of analyses in the research
above, suggesting that results should be interpreted cautiously.
37
In contrast to the above argument, other researchers maintain that ambivalent
attachment is more strongly linked to the development of childhood anxiety disorders
(Cassidy & Berlin, 1994). This is thought to occur in response to worry brought about by the
inconsistent availability of the parent in times of distress (Shamir-Essakow, Ungerer, &
Rapee, 2005; Warren, Huston, & Egeland, 1997), leading to feelings of vulnerability and
resulting in persistent anxiety. Evidence for this argument was reported in a longitudinal
study by Warren et al. (1997), investigating the link between attachment style and the
development of anxiety disorders in 172 children. Participants and their mothers were
assessed when the infants were 12 months of age, with children screened for
psychopathology at 17.5 years of age. It was found that participants with an ambivalent
attachment pattern as infants were significantly more likely to meet criteria for an anxiety
disorder at 17, even after the effects of maternal anxiety and infant temperament were
controlled. Most recently, longitudinal research by Brumariu and Kerns (2008) identified the
link between attachment style and three aspects of social anxiety: fear of negative evaluation,
social avoidance and distress in new situations, and generalised social avoidance and distress.
Ambivalent attachment earlier in childhood predicted all three aspects of social anxiety, and
children with lower attachment security and higher ambivalent attachment were more likely
to self-report social anxiety.
Whilst there remains some discussion as to whether ambivalent or avoidant
attachment styles are more conducive to the development of anxiety disorders in children, the
above evidence clearly demonstrates that at the very least, children with insecure attachment
styles appear to be at significantly greater risk of developing anxiety symptomatology. It
38
therefore appears that attachment style constitutes a significant risk factor for childhood
anxiety.
Life events. Exposure to stressful experiences and traumatic events may contribute to
the development of anxiety in children, particularly in those who are predisposed to these
disorders (Boer et al., 2002; Grant, Compas, Thurm, & McMahon, 2004; Rapee & Szollos,
2002). A range of negative events may result in anxiety difficulties, ranging from acute
stressors such as accidents, natural disasters, the death of a loved one, and changing schools,
to more chronic psychosocial stressors such as dysfunctional parent-child relationships,
parental psychopathology, domestic violence, poverty, financial stress and low socio-
economic status, sustained physical or sexual abuse, chronic illness, and bullying (Bandelow
et al., 2004; Donovan & Spence, 2000). In some cases, anxiety following negative life events
is acute, and may resolve reasonably quickly. For other children however, anxiety may
persist and interfere with everyday functioning. Associations between childhood anxiety and
negative life events have been found both prospectively and retrospectively, with evidence
for both discussed below.
A small body of prospective research has demonstrated an increased incidence of
anxiety symptoms and diagnosable anxiety disorders in children in the wake of exposure to
traumatic or stressful life events and situations (Dollinger, O'Donnell, & Staley, 1984;
Goodyer, 1996; Rueter, Scaramella, Wallace, & Conger, 1999; Terr, 1981; Yule & Williams,
1990). Early research by Dollinger et al. (1984) found increased self-reported fear in children
who had witnessed a fatal lightning strike during a sports match, compared to a matched
control group. Symptoms noted in this cohort included avoidance behaviours, intrusive
thoughts, poor sleep, and somatic complaints (Dollinger, 1986; Dollinger et al., 1984). A
39
later study investigated the longitudinal effect of family conflict in 303 families with at least
one child aged 12 to 13 years. The children were assessed for anxiety and depressive
disorders at age 19 or 20. Participants with greater parent-adolescent discord at the age of 12
to 13 were at a significantly greater risk of anxiety in late adolescence/early adulthood,
demonstrating the effect of a chronic stressor on anxiety.
Most recently, McLaughlin and Hatzenbuehler (2009) attempted to demonstrate a
longitudinal link between stressful life events, anxiety sensitivity, and development of
anxiety symptomatology. Anxiety sensitivity refers to the fear of anxiety symptoms, based
upon beliefs that such symptoms may be socially, physiologically, or psychologically
harmful to the individual (Reiss, 1991). Anxiety sensitivity has been recognised as a risk
factor for the development of anxiety disorders in both children and adults. McLaughlin and
Hatzenbuehler (2009) hypothesised that exposure to stressful life events would increase
propensity for anxiety sensitivity, which would in turn contribute to changes in anxiety
symptoms over time. This large-scale longitudinal study assessed stressful life events,
anxiety sensitivity, and internalising symptoms in 1065 adolescents at three different time
points across a 7-month period. Results indicated that exposure to stressful life events,
particularly those related to health and family discord, was associated with longitudinal
increases in anxiety sensitivity. As predicted, anxiety sensitivity was found to mediate the
relationship between stressful life events and anxiety symptoms. This research has
implications for future intervention and prevention research, suggesting that intervention
components which address fearful cognitions relating to anxiety symptoms may in part buffer
the effects of stressful life events, and thereby assist in reducing anxiety symptoms in
children.
40
In contrast to the prospective research above, retrospective research into the link
between life events and anxiety disorders has been more prolific, with results demonstrating
that anxious children are significantly more likely to have experienced a greater number of
negative events, compared to non-anxious children (Benjamin, Costello, & Warren, 1990;
Boer et al., 2002; Duggal et al., 2000; Goodyer & Altham, 1991; Sandberg, McGuinness,
Hillary, & Rutter, 1998). Allen, Rapee, and Sandberg (2008) compared the degree of
exposure to severe life events in children with anxiety disorders and a non-disordered control
group. Mothers of children in both groups were interviewed regarding their child’s
retrospective experience of chronic adversities and severe life events. Results indicated that
anxious children were exposed to significantly more chronic adversities and severe life events
than control children prior to the onset of their disorder, a finding which has replicated that of
earlier research (Boer et al., 2002).
Some researchers have chosen to focus on links between stressful life events and
specific anxiety diagnoses. Bandelow et al. (2004) conducted retrospective interviews
tapping childhood traumatic experiences with social anxiety disorder (now referred to as
SOP) patients, and a healthy control group. Anxious individuals reported significantly more
traumatic childhood experiences than controls, including being separated from parents,
parental marital discord, sexual abuse, familial violence, and childhood illness. They were
also more likely to report greater dissatisfaction with their parents’ rearing style, and greater
rates of psychiatric disorders (including anxiety disorders) in their families. Other
researchers have focused on rates of negative life events and obsessive compulsive disorder
(OCD) in childhood. Gothelf, Aharonovsky, Horesh, Carty, and Apter (2004) found that
children with OCD and children with another (unspecified) anxiety disorder experienced
significantly more negative life events than healthy controls, in the year prior to disorder
41
onset. The two anxiety groups did not differ in terms of the mean number of life events
experienced, with ‘major illness or injury of a relative’ the only life event significantly more
common in the OCD group. Regardless of the diagnosis considered, it seems clear that
exposure to traumatic and stressful life events constitutes an overt risk for anxiety problems
in children.
The above section reviewed several well-established environmental risk factors for
anxiety. The literature on parental psychopathology suggests that having an anxious parent
may predispose children to developing anxiety themselves, with this association having been
found in both cross-sectional and longitudinal research. Certain types of parenting
behaviours have also been identified as a significant risk factor for childhood anxiety, with
children of parents who model or reinforce anxious behaviours at greater risk of negative
outcomes. The quality of attachment between child and parent has also been implicated in
the development of anxiety in children. Both avoidant and ambivalent attachment styles have
been linked to increased risk of anxiety disorders, highlighting the importance of a secure
early attachment to the primary caregiver to long term positive mental health. Lastly, both
prospective and retrospective research has demonstrated that children exposed to traumatic or
stressful life events are at greater risk of developing an anxiety disorder. The research
reviewed highlights the important influence that a child’s environment may have on their
mental health outcomes, both immediately and in the future.
Protective Factors
Not all children with risk factors for childhood anxiety progress to the stage of
diagnosable disorder. This key point has lead to the investigation of various protective
factors for anxiety, which may provide resilience against psychological dysfunction (Coie et
al., 1993; Donovan & Spence, 2000). Protective factors identified in the literature are
42
generally classified as either child intrinsic, familial, or environmental in nature (Coie et al.,
1993; Donovan & Spence, 2000; Masten & Powell, 2003; Rutter, 1985). The mechanism of
action for protective factors varies widely, and may include providing direct protection from
risk, mediating the relationship between risk factors and anxiety, and acting as a buffer
against risk factors (Cole, Michel, & Teti, 1994; Donovan & Spence, 2000; Wheaton, 1986).
Compared to the wealth of literature investigating risk factors for childhood anxiety, research
into protective factors has been considerably less prolific. As research into anxiety
prevention progresses however, there is growing interest in the understanding of protective
factors, and their role in preventative intervention. The following section reviews the
available literature on key identified protective factors for anxiety disorders in children.
Child Protective Factors
Research has identified several child-centred factors which may protect against the
development of anxiety problems in childhood, including coping skills, locus of control, and
emotional regulation (Masten & Powell, 2003). These will be discussed below.
Coping skills. Coping skills is one of the most empirically established child factors
which protects against anxiety and other childhood psychopathology (Muris, Schmidt,
Lambrichs, & Meesters, 2001). The term refers to the various techniques and processes used
to cope with a challenging or unpleasant experience or situation. The repertoire of coping
skills and strategies that a child possesses can shape the way they respond to difficult or
negative experiences, and thereby influence their affective and behavioural response
(Donovan & Spence, 2000). The use of appropriate coping skills can mediate the relationship
between such negative experiences, and psychological wellbeing (Folkman, Lazarus, Gruen,
& DeLongis, 1986). Effective coping skills include the use of positive strategies such as
43
thought challenging, positive self-talk, help-seeking, and problem-solving, to address the
problematic issue. By comparison, maladaptive coping skills tend to be emotion-focused,
resulting in cognitive and behavioural avoidance of the stressor, which ultimately reinforces
anxiety (Billings & Moos, 1981; Carver, Scheier, & Weintraub, 1989; Endler & Parker, 1990;
Folkman & Lazarus, 1980, 1985).
Research with adolescents and adults has demonstrated that problem-based coping,
and cognitive appraisals based on an internal locus of control are associated with better
psychological outcomes. These outcomes include decreased risk of psychological
dysfunction, fewer internalising symptoms, improved academic achievement, social
competence, and improved psychological adjustment in general (Cauce, Stewart, Rodriguez,
Cochran, & Ginzler, 2003; Compass, Malcarne, & Fondaraco, 1988; Herman-Stahl &
Petersen, 1996; Lengua, Sandler, West, Wolchick, & Curran, 1999; Luthar, 1991; Luthar &
Zigler, 1992; Muris et al., 2001; Plancherel & Bolognini, 1995). By comparison, emotion-
focused coping strategies that facilitate avoidance are associated with poorer psychological
outcomes, including anxious symptomatology and anxiety disorders in adults (Carver et al.,
1989; Edwards & Trimble, 1992; Jeavons, Horne, & Greenwood, 2000; Whatley, Foreman,
& Richards, 1998; Windle & Windle, 1996; Zeidner & Ben-Zur, 1994). Similarly, emotion-
focused coping and avoidance is associated with increased risk of anxiety, depression, and
behavioural problems in adolescence (Compass et al., 1988; Ebata & Moos, 1991).
Overall, the evidence suggests that coping skills that encompass a problem-based
approach, adequate appraisal, and greater perceived control will enable children to approach
and manage difficult and negative situations in more adaptive ways. Children who lack these
skills are poorer-equipped to face challenging situations through lacking the ability to
44
appraise the situation more appropriately, which may moderate the impact of such
experiences upon mental wellbeing (Hudson, Flannery-Schroeder, & Kendall, 2004). This
highlights the importance of coping skills as a buffer against anxiety, suggesting that the
amelioration of maladaptive coping should form a significant part of preventative
interventions for childhood anxiety disorders.
Emotional regulation. Emotional regulation, or the ability to monitor, evaluate, and
modify the intensity and duration of emotional states to achieve social and biological
adaptation and individual goals (Eisenberg, Fabes et al., 1997; Eisenberg, Guthrie et al.,
1997), may also exert a protective influence against childhood anxiety. Emotional regulation
is the process of managing emotional arousal, and is required for the development of healthy
relationships and the ability to successfully negotiate the many challenges of life
(Hannesdottir & Ollendick, 2007). By comparison, emotional dysregulation, characterised by
an impaired ability to control emotional arousal, results in maladaptive coping mechanisms
and reinforces distorted cognitions, hindering both the ability to engage appropriately with
others, and to respond adaptively to various situations (Cole et al., 1994; Hannesdottir &
Ollendick, 2007). In the case of childhood anxiety disorders, emotional dysregulation may
manifest through emotional and physiological arousal stemming from distorted cognitions.
The inability to appropriately regulate this arousal typically results in the maladaptive coping
strategy of avoidance (Mash & Wolfe, 2002), which reinforces anxiety.
Emotional dysregulation has been found to be more common in anxious children.
Southam-Gerow and Kendall (2000) noted that anxious children lack knowledge about their
ability to mask or manipulate the outward expression of emotion for the purpose of achieving
interpersonal goals, compared to non-anxious children. It is also known that anxious children
45
attempt to avoid situations that elicit intense emotional arousal (Mash & Wolfe, 2002), which
is typical of emotional dysfunction. More recently, Suveg and Zeman (2004) demonstrated
that when anxious children do find themselves in such situations, they have limited skills to
handle their emotions. Specifically, anxious children are more likely to experience negative
emotions more intensely, to have dysregulated expressions, to demonstrate less adaptive
coping, and to report lower self-efficacy in their ability to alter their mood than non-
disordered children (Suveg & Zeman, 2004). This research highlights the pattern between
emotional regulation and anxiety, and the emotional and behavioural impact of the inability
to effectively regulate emotions.
Given that emotional dysregulation is related to impairment in several indicators of
successful functioning (Thompson, 1994), it therefore follows that healthy emotional
regulation should be associated with better mental health outcomes. Evidence to this nature
was provided by Buckner, Mezzacappa, and Beardslee (2003), who investigated the link
between emotional regulation and resilience in 155 children aged 8 to 17. Children who were
more adept at emotional regulation scored better on measures of emotional well-being and
mental health. Other researchers have found that factors linked to emotional regulation, such
as positive self-esteem, ego resilience and ego control, are associated with greater resilience
and improved mental well-being in children with multiple risk factors for psychopathology
(Cicchetti, Ackerman, & Izard, 1995; Cicchetti & Rogosch, 1997; Cicchetti, Rogosch, Lynch,
& Holt, 1993). Eisenberg, Fabes et al. (1997) found that high emotional regulation was
associated with higher-quality social functioning (encompassing constructs such as social
skills and pro-social behaviour), and lower levels of negative emotionality. Taken together
the evidence suggests that children with better control over their emotions are less vulnerable
to a range of negative psychosocial outcomes, and that emotional regulation may protect
46
against anxiety and other forms of psychopathology (Buckner et al., 2003; Werner & Smith,
1992). It follows then that interventions that teach children to identify and manage emotions
may provide a protective effect against the development of childhood anxiety.
Family and Environmental Protective Factors
Beyond child-centred protective factors for childhood anxiety, several environmental
factors have also been identified which may exert a protective influence against anxiety.
More specifically, these factors are those inherent to the familial and social systems within
which the child functions. Evidence for the protective nature of family and community
variables will be discussed below.
A supportive and nurturing family environment is conducive to normal child
development and mental wellbeing. A component of this that is postulated to protect against
anxiety is a secure attachment to a parent or caregiver (Greenburg, 1999; Masten, 2001). This
type of relationship, characterised by warmth, openness, and responsive parenting, may
protect against anxiety through the promotion of healthy childhood adjustment, including
social and emotional development, and academic achievement (Kim-Cohen, Moffit, Caspi, &
Taylor, 2004; Luthar & Latendresse, 2005; Masten, 2001; Radke-Yarrow & Brown, 1993;
Vanderbilt-Adriance & Shaw, 2008; Werner & Smith, 1992). The protective effect of a
secure attachment has been found regardless of risk status; children with a secure attachment
during infancy tend to display fewer symptoms of anxiety by the time they reach school-age,
in both high and low risk populations (Booth, Rose-Krasnor, McKinnon, & Rubin, 1994;
Dallaire & Weinraub, 2005; Goldberg, Gotowiec, & Simmons, 1995). Recent research by
Dallaire and Weinraub (2007) found that even when gender, family income, maternal
47
sensitivity, and past anxiety were controlled for, children with a more secure mother-child
attachment at age 15 months were less likely to display anxiety symptoms at 4.5 years of age.
By comparison, children who lack a secure attachment to a parent or caregiver face an
increased risk for negative psychosocial and emotional outcomes (Greenburg, 1999).
Research with institutionalised children has shown that the psychological and behavioural
impacts of emotional deprivation, and lack of secure caregiver attachment, can be long
lasting and severe, and permeate other aspects of life well into adolescence and adulthood
(Beckett et al., 2006; MacLean, 2003). It has also been found that children classified as
insecurely attached at 15 months of age are significantly more anxious than children with a
secure parent-child attachment, regardless of the impact of negative life events. Other
research has highlighted that even an affluent upbringing fails to ameliorate the negative
effects of a deficient caregiver-child attachment (Luthar & Latendresse, 2005). Additional
literature regarding the negative effects of insecure attachment has been reviewed elsewhere
(see section on Risk Factors).
One protective factor which may be promoted both via the family and the community
is that of social support, which may buffer against the effects of several risk factors for
childhood anxiety. For example, social support has been shown to mediate the effect of
negative, traumatic, or stressful life events, leading to reduced risk of psychological disorder
(Cowen, Pedro-Carroll, & Alpert-Gillis, 1990; Murray, 1992; Spaccarelli & Fuchs, 1997;
White, Bruce, Farrell, & Kliewer, 1998). Social support within the family has been
highlighted as particularly beneficial in protecting children from anxiety. Longitudinal
research by White et al. (1998) found that children exposed to community violence who
received a high degree of familial social support were significantly less likely to be anxious.
48
A similar study investigating the effect of community violence on primary school children
found that both trait and state anxiety were lower in children with higher levels of social
support (Hill, Levermore, Twaite, & Jones, 1996). Social support from sources outside of the
home is also associated with positive mental health outcomes. Social support from
schoolmates and friends (Cowen et al., 1990; Hill et al., 1996; Varni, Setoguchi, Rappaport,
& Talbot, 1992), teachers (Danielsen, Samdal, Hetland, & Wold, 2009; Davidson &
Demaray, 2007; Huebner, Suldo, Smith, & McKnight, 2004) and sports coaches (Smith,
Smoll, & Barnett, 1995) have all been associated with improved indices of psychosocial
functioning.
Environmental factors within both the family unit and the wider community can exert
a crucially important protective effect against childhood anxiety. With regards to the family,
a stable and secure attachment to the parent or caregiver has been shown to protect against
the negative effects of stressful or traumatic events and situations, for children in both high
and low risk populations. Additionally, the positive benefits of social support, both within
the family and in the community in general, are associated with lower rates of anxiety in
children.
Summary
This chapter reviewed a selection of factors associated with increased risk of
childhood anxiety disorders. It is clear from this review that the aetiology of anxiety
disorders is complex, with a range of biological, psychological, and environmental risk
factors implicated in the development of clinical anxiety. Whilst individually they constitute
an increased risk for disordered functioning, the interaction and interconnectedness between
these factors makes it difficult to disentangle the effects of any single variable, and to infer a
49
causal relationship with anxiety. Despite this, risk factors for childhood anxiety may be used
to identify those individuals who are most vulnerable to poorer outcomes in general, and
provide targets for intervention and prevention of anxiety.
The current chapter also focused on protective factors for childhood anxiety,
including child-intrinsic, family-intrinsic, and environmental factors. This review highlighted
the important role of such factors in buffering against the effects of risk factors, and reducing
the likelihood of developing clinical anxiety.
Perhaps the most poignant conclusion that can be reached from the above literature
review is that the current understanding of protective factors for resilience against childhood
anxiety pales in significance compared to the wealth of literature on risk factors for childhood
anxiety disorders. Whilst knowledge of risk factors is undeniably crucial in identifying
populations in need of intervention, a better understanding of protective factors is required to
inform the content of such interventions, in the interest of maximising effectiveness.
Literature on both risk and protective factors has been heavily drawn upon in research of
treatment for childhood anxiety disorders, with interventions traditionally targeting
individuals and groups with multiple risk factors or an established disorder. Concurrently,
growing understanding of protective factors has enabled tailoring of these interventions to
enhance resilience and mental wellbeing in children with anxiety disorders, with promising
results.
The following chapter reviews literature on interventions for established anxiety
disorders in childhood. Early treatments based on the individual therapy model are reviewed,
followed by an exploration of studies evaluating group-based interventions.
50
CHAPTER THREE: TREATMENT OF CHILDHOOD ANXIETY DISORDERS
In response to greater awareness of the prevalence of childhood anxiety disorders,
extensive research has been conducted over the last few decades into treatment of childhood
anxiety disorders. Early treatment approaches for children suffering from clinically
diagnosed anxiety were typically downward extensions of empirically validated treatments
for adult populations, made appropriate for children (Cartwright-Hatton & Murray, 2008).
Of these, cognitive behavioural therapy (CBT) is typically cited as the gold standard
treatment for childhood anxiety (Compton et al., 2004; Ollendick & King, 1998). CBT
addresses the cognitive, behavioural, and physiological elements of anxiety, through
treatment components including relaxation training, cognitive restructuring, exposure and
response prevention, and problem-solving. The efficacy of CBT as a treatment for anxiety in
children has been extensively validated. In a systematic review, Cartwright-Hatton, Roberts,
Chitsabesan, Fothergill, and Harrington (2004) report that trials evaluating CBT for
childhood anxiety have reported success rates approximating 60%. Furthermore, CBT for
childhood anxiety has been found to be equally as effective when delivered as an individual
or group intervention (Barrett, 1998; Shortt, Barrett, & Fox, 2001; Silverman et al., 1999).
The following section briefly reviews the progression of research into CBT as a treatment for
childhood anxiety, from its origins as an individual treatment modality, to its development
into a successful group intervention.
Individual CBT
Early research into CBT for the treatment of childhood anxiety disorders focused on
intervention at an individual level. The first randomised clinical trial of individual CBT for
childhood anxiety was conducted by Kendall (1994), in an evaluation of Coping Cat - a 16-
51
session manualised CBT treatment program for anxious children. The program was
comprised of components such as affective recognition, relaxation, cognitive restructuring,
and problem-solving. This study involved 47 children aged 9 to 13 years, each with a
diagnosis of either OAD, avoidant disorder (now referred to as SOP), or SAD. All children
were assessed via clinical interview to confirm diagnostic status. In conjunction with the
child-focussed treatment, parents of the children also participated in two additional sessions,
allowing the therapist to update them on their child’s progress.
The above intervention proved to be a success. Within the active treatment condition,
64% of the participants no longer qualified for a diagnosis at the completion of the program,
compared to 5% of the participants in the wait-list control group (Kendall, 1994). Significant
positive gains were noted from pre to post-treatment on parent-report, child-report, and
behavioural measures, with these gains maintained at 12 months follow-up. The efficacy of
the intervention was cemented by a later replication study involving a larger sample of
children (n=97) aged from 9 to 13 years (Kendall et al., 1997). By the completion of
treatment, 53% of children who received CBT were diagnosis-free, compared to only 6% of
children in the wait-list condition. For those children in the active condition who still met
criteria for an anxiety disorder post-treatment, measures of clinical severity for their disorder
had significantly decreased. Further support was provided by long term follow-up of the
original Kendall (1994) sample. The positive gains achieved in this first study were not only
maintained, but also enhanced, at both three years (Kendall & Southam-Gerow, 1996b) and
7.5 years (Kendall, Safford, Flannery-Schroeder, & Webb, 2004) post-treatment. This early
work demonstrated that childhood anxiety could be successfully treated using CBT on an
individual basis, forming the foundation for further research into treatment of childhood
anxiety disorders.
52
Following pioneering work by Kendall (1994), other researchers expanded on the
individual CBT treatment model by including a family component, which acknowledged the
role that parents play in maintaining childhood anxiety (Hudson, 2005). Barrett, Rapee et al.
(1996) conducted the first study on family-based CBT intervention for anxious children. The
study included a sample of 79 children aged 7 to 14 years, each with a diagnosis of GAD,
SOP, or SAD. Children were randomly allocated to one of three conditions: individual CBT,
individual CBT plus a family component (CBT + FAM), or a wait-list condition. The family
component taught parents skills designed to assist them in managing their child’s anxiety
(including contingency management, communication skills, and problem solving), whilst
educating them about how to manage their own anxiety. At post-treatment, CBT + FAM was
shown to be more efficacious; 87% of children in this condition no longer met diagnostic
criteria for an anxiety disorder, compared to 57% of children in the CBT only condition, and
26% of children in the wait-list condition. Whilst no significant differences were noted
between the treatment groups at 6 months follow-up, by 12 months follow-up the significant
positive gains resurfaced, with 95% of children who received CBT + FAM diagnosis free,
compared to 70% of children who received CBT only. This research demonstrates that whilst
child-focused and family-focused CBT are significantly more effective treatments for
childhood anxiety, additional clinical benefits may be afforded by the inclusion of parents in
the intervention.
Since the above study was published, other researchers have further investigated
individual CBT for childhood anxiety when packaged with a family component. Recently,
Wood, Piacentini, Southam-Gerow, Chu, and Sigman (2006) compared a child-focused
individual CBT intervention for anxiety with a family-focused CBT intervention, the
53
Building Confidence program. This program was comprised of traditional child-focused CBT
strategies plus an added parent training component, focusing specifically on changing the
communication patterns of parents which were theorised to maintain child anxiety.
Participants included 40 children aged 6 to 13 years with diagnosed SAD, SOP, or GAD.
Consistent with the earlier research, significant improvements were noted in both the child-
focused and family-focused CBT groups post-treatment. Greater improvements, however,
were noted for the latter group, in terms of both the diagnostician’s ratings of anxiety
severity, and parental report of anxiety symptomatology. The same pattern of results was
found at long term follow-up; positive gains were maintained 12-months post-treatment, with
diagnostician and parent ratings indicating greater reductions of anxiety for children in the
family CBT condition (Wood, McLeod, Piacentini, & Sigman, 2009). These findings
compliment those of Barrett, Rapee et al. (1996), and further support the inclusion of parents
in individual interventions for childhood anxiety.
A similar comparison of the relative efficacy of individual child-based and family-
based CBT interventions for childhood anxiety was conducted by Kendall, Hudson, Gosch,
and Flannery-Schroeder (2008), who compared these two treatment modalities against a third
condition: family-based education, support, and attention (FESA). The study involved 161
children aged between 7 and 14 years with a diagnosable anxiety disorder. At post-treatment,
children in both CBT conditions were significantly more likely to be diagnosis free, relative
to children in the FESA condition. There were no significant differences in rates of diagnosis
between the two CBT treatments at post-treatment, though teacher reports of anxiety
decreased significantly for children in the child-based CBT condition following treatment.
Importantly, the gains of children in both CBT groups were maintained at 12 months follow-
up. It was also noted that, for children of parents who both met criteria for an anxiety
54
disorder themselves, the family-based CBT condition was associated with greater
improvement in child outcomes. In contrast to earlier research (Barrett, Dadds et al., 1996;
Wood et al., 2006), this study found that child-based and family-based CBT for childhood
anxiety may be equally as efficacious, though the latter treatment model is likely to be more
effective for children of anxiety-disordered parents.
As discussed above, the positive effects of individual CBT for childhood anxiety have
been well established. Beyond immediate treatment effects, longitudinal research
demonstrating maintenance of treatment gains up to seven years post-treatment (Barrett,
Duffy, Dadds, & Rapee, 2001; Kendall & Southam-Gerow, 1996a; Kendall et al., 2004) has
significantly bolstered the continued use of CBT interventions for this type of individual
therapy with children. Research comparing child-focused interventions to family-focused
interventions suggests that, whilst both modalities are efficacious, the inclusion of a parental
component in traditional individual CBT interventions for children may afford additional
treatment benefits (Barrett, Dadds et al., 1996) (Wood et al., 2006), and that these benefits are
similarly robust over time (Wood et al., 2009).
Group CBT
Given that the efficacy of individual CBT has been well established (Hudson, 2005;
King, Heyne, & Ollendick, 2005), more recent research has shifted towards the evaluation of
group CBT for childhood anxiety disorders. Group interventions constitute a more efficient
treatment model than individual therapy treatments, in that the intervention ‘dosage’ can be
administered to larger numbers of anxious children simultaneously (Hudson, 2005).
Furthermore, group processes add another dimension to the standard individual CBT
intervention, with greater opportunities for encouragement and reinforcement, peer support,
normalisation of experiences, modelling, and sharing of resources among participants
55
(Albano, Marten, Holt, Heimburg, & Barlow, 1995; Heimburg et al., 1990; Kazdin, 1994). In
addition to these benefits, group CBT may be significantly more cost-effective, with a single
therapist able to deliver an intervention to a group of children in the same time that would be
devoted to an individual therapy program (Hudson, 2005; King et al., 2005). For this reason,
group intervention is also a time-effective alternative to individual therapy with anxious
children.
The first study investigating group CBT for anxiety disorders in children was
conducted by Barrett (1998). A sample of 60 children aged 7 to 14 years with a clinical
diagnosis of OAD, SAD, or SOP were randomly allocated into one of three conditions:
GROUP-CBT (child only condition), GROUP-FAM (child + family management training) or
wait-list control. Participants in both treatment conditions completed the Coping Koala
intervention program, a 12-week group CBT program for anxiety, and an Australian
adaptation of the Coping Cat program (Kendall, 1990). Post treatment, 56% and 71% of
children from the GROUP-CBT and GROUP-FAM conditions respectively were diagnosis
free, as compared to 25% of children from the wait-list control. These gains were maintained
over time, with 65% of children in the GROUP-CBT condition and 85% of children in the
GROUP-FAM condition diagnosis-free 12-months post-intervention. In comparison to
Barrett, Dadds et al.'s (1996) earlier study, group CBT was found to be equally as efficacious
as individual CBT in the treatment of childhood anxiety, both immediately post-treatment
and at 12 months follow-up, indicating group CBT to be a successful and efficient option for
treatment of childhood anxiety.
Early findings by Barrett (1998) have been bolstered by further clinic-based research
into group CBT for anxiety disorders in childhood. Silverman et al. (1999) investigated the
56
efficacy of a group CBT intervention for anxiety (incorporating concurrent parent sessions),
relative to a wait-list control group. Children in the active condition were significantly more
likely to be diagnosis free post-treatment, and showed significant improvements based on
both child and parent report measures of symptomatology. The positive effects of treatment
were still evident at 12 months follow-up. Later, a randomised clinical trial conducted by
Shortt, Barrett, and Fox (2001) compared a 10-session group family CBT intervention for
anxious children, the FRIENDS Program for Children (Barrett, Lowry-Webster, & Turner,
2000), against a wait-list control group. Participants included 71 children (aged 6 to 10
years) with a diagnosis of SAD, GAD, or SOP, who were randomly allocated to either the
treatment or wait-list condition. At post-treatment, 69% of children who received the group
intervention were diagnosis free, compared to 6% of children in the wait-list condition.
These treatment gains were maintained at 12 months follow-up, with 68% of children in the
treatment condition remaining diagnosis-free. Most recently, Hudson et al. (2009)
established that a group-based CBT intervention for childhood anxiety was superior to a non-
specific therapy intervention (designed to provide support and build relationships between
and within families) in reducing anxiety, with 68.8% of children in the CBT condition
diagnosis-free at 6 months follow-up, compared to only 45.5% of children in the active
control group. This research clearly demonstrates that group CBT is associated with greater
decreases in anxiety than both wait-list conditions and non-specific therapy formats.
Whilst time and cost-effectiveness clearly make group CBT a more attractive option
than individual CBT for the treatment of childhood anxiety, more importantly, the
effectiveness of the intervention is not compromised by group delivery. Flannery-Schroeder
and Kendall (2000) compared the treatment efficacy of individual CBT and group CBT for
anxiety disordered children. The sample consisted of 37 children (aged from 8 to 14 years)
57
with a diagnosis of GAD, SOP, or SAD. As predicted, children from both individual and
group CBT conditions were significantly less likely to meet diagnostic criteria for an anxiety
disorder post-intervention than children from a wait-list control condition. With regards to
outcome differences between the two active conditions, 73% of children in the individual
CBT condition were diagnosis free post-treatment, compared to 50% of children in the group
condition. This difference was not statistically significant, indicating that group CBT for
childhood anxiety can be considered to be an efficacious and efficient alternative to
individual treatment for this population.
Similar comparisons between individual and group CBT for childhood anxiety have
subsequently been published. Manassis et al. (2002) used a larger sample of 78 children
(aged 8 to 12 years) with diagnosable anxiety disorders (including GAD, SAD, SOP, PD, and
SP) to compare treatment efficacy of individual and group CBT. Both conditions included a
parent training component, which taught parents how to assist their children in coping with
anxious situations. Consistent with earlier research (Flannery-Schroeder & Kendall, 2000),
there was no significant difference in terms of program efficacy, and both individual and
group therapy were associated with reduced rates of diagnosable disorders post-intervention.
Most recently, a similar comparison was conducted by Liber et al. (2008), who evaluated
individual and group CBT for anxiety using the FRIENDS program intervention protocol.
Again, group CBT was found to be equally as effective as individual CBT in treating
diagnosable childhood anxiety disorders.
Following from research comparing individual CBT interventions to those with an
added parent component (Barrett, Dadds et al., 1996; Wood et al., 2006), Cobham, Dadds,
and Spence (1998) investigated what effect an added parental anxiety management
58
component (CBT + PAM) would have to n group CBT intervention for childhood anxiety.
This research was conducted with children of anxious parents, and children of parents
without an anxiety diagnosis. For the latter group, no significant difference in rates of
diagnosable anxiety was evident at post-treatment between the CBT and CBT + PAM groups.
A striking difference, however, was observed for children with anxious parents: 77% of these
children in the CBT + PAM condition were diagnosis-free, compared to only 39% for the
CBT only group. Clearly then, having an anxious parent appears to significantly compromise
the effectiveness of child-focused CBT for child anxiety, and CBT interventions with an
added parental component may be more effective for this group of children.
Later, Mendlowitz et al. (1999) expanded on the above research by comparing three
different intervention conditions for anxious children aged 7 to 12 years: parent and child
CBT, child only CBT, and parent only CBT. Whilst both anxious and depressive
symptomatology decreased significantly from pre to post-treatment in each of the three
conditions, greater improvements were noted for children in the combined parent and child
condition in terms of emotional well-being, as reported by parents. Children in the combined
group were also more likely to use more active coping strategies post-treatment, than those in
the other treatment groups. This research further indicates that the inclusion of parents in
group CBT programs for childhood anxiety may be associated with increased benefits to the
child, especially for those children with anxious parents.
Summary
This chapter has reviewed literature evaluating CBT as an intervention for children
with established anxiety disorders. The research in this domain supports the use of group
CBT as an efficacious, cost-effective, and time-effective treatment modality for childhood
59
anxiety, with demonstrated benefits over time (Barrett, 1998; Hudson et al., 2009; Shortt,
Barrett, & Fox, 2001; Silverman et al., 1999). Group CBT has been demonstrated to be as
effective as individual CBT in terms of treatment effects (Flannery-Schroeder & Kendall,
2000; Liber et al., 2008; Manassis et al., 2002), and treatment benefits may be improved
where the intervention is packaged with a parent component (Cobham et al., 1998;
Mendlowitz et al., 1999). Group-based CBT appears to be the treatment of choice for
children and adolescents with established anxiety disorders, however with greater
understanding of the growing issue of childhood anxiety in today’s society, researchers have
shifted focus from the treatment model to prevention. The issue of prevention of childhood
anxiety will be examined in the following chapter, with a particular focus on research
developments in this area.
60
CHAPTER FOUR: PREVENTION OF CHILDHOOD ANXIETY DISORDERS
Despite ongoing research into treatments for childhood mental illness, and continued
refinement and evaluation of intervention protocols, the majority of children with a
psychological disorder do not receive the treatment they require, whilst those who do often
terminate prematurely or do not improve following treatment (Donovan & Spence, 2000;
Essau, 2005; Farmer, Burns, Phillips, Angold, & Costello, 2003; Farrell & Barrett, 2007;
Hirschfeld et al., 1997; Olfson et al., 2003; Sawyer et al., 2000). Epidemiological research
has demonstrated that untreated anxiety disorders in childhood typically become entrenched
during adolescence and well into adulthood (Burke, Burke, Reiger, & Rae, 1990; Costello et
al., 2004; Dadds et al., 1999; Orvaschel et al., 1995). Further to this, the developmental
pathway of anxiety is well documented, with longitudinal research demonstrating a clear link
between childhood anxiety and subsequent development of depression, suicidality, substance
abuse, personality psychopathology, and other psychiatric disorders (Angold et al., 1999;
Cole et al., 1998; Last et al., 1996; Lewinsohn, Zinbard, Seeley, Lewinsohn, & Sack, 1997;
Rudd et al., 2004; Woodward & Fergusson, 2001). Untreated anxiety can compromise social,
emotional, and academic functioning (Donovan & Spence, 2000), resulting in poor social and
coping skills, low self-esteem, social isolation, and academic underachievement (McLoone et
al., 2006; Rapee et al., 2005). Across the life-course, these factors may limit vocational
opportunities, and contribute towards the development of depression and substance abuse in
adulthood (Donovan & Spence, 2000; Neil & Christensen, 2009; Rapee et al., 2005).
Whilst increased research into childhood anxiety has highlighted the importance for
timely intervention, there is no guarantee that children with anxiety will receive appropriate
psychological treatment. Many barriers exist to both access to, and engagement with, mental
61
health services for children. Owens et al. (2002) posit that there are three categories of
barriers to accessing child mental health services. The first category is structural barriers,
whereby access to services is limited by a lack of available services and long waiting lists,
due to increased demand on community mental health services (Donovan & Spence, 2000).
An additional structural barrier includes the inability to pay for private services, which are
beyond the financial means of many families (Snell-Johns, Mendez, & Smith, 2004). The
second category is barriers related to perceptions about mental illness, including the
proficiency of parents, teachers, and health care providers in identifying children requiring
assistance, denial of the severity of a child’s mental health problem, and beliefs that the
mental health problem does not require treatment (Esser et al., 1990; Halfon, Inkelas, &
Wood, 1995; Owens et al., 2002; Zubrick, Silburn, Burton, & Blair, 2000). The third
category is barriers related to perceptions about mental health services themselves, including
lack of trust, previous negative experience with mental health services, and stigma attached to
being treated for a mental illness (Flisher et al., 1997; Hoagwood et al., 2000; Stiffman et al.,
2000). These barriers may also be a factor in early termination of treatment, for those
children who progress to treatment phase (Kazdin, 1996). Barriers to mental health services
are discussed in more detail in Chapter 5.
The above barriers to accessing mental health services are heavily implicated in the
under-treatment of childhood anxiety disorders, which has dire consequences on a macro
level. The global public health burden of mental illness is already substantial, with
considerable negative impacts to the global economy. A report in the United States
investigated the financial burden of mental health services for children aged 1 to 17; it
reported a total yearly treatment expenditure estimate of $11.75 billion dollars, with inpatient
treatment, outpatient treatment, and medication costs accounting for 57%, 33%, and 9% of
62
the total expenditure respectively (Ringel & Sturm, 2001). With specific regard to anxiety,
Greenberg et al. (1999) estimated that in the decade of the 1990s, anxiety disorders cost the
USA alone in excess of $42 billion dollars, with the financial mental health burden projected
to rise even higher in the future. These projections, taken with the above research, suggest
that not only does the need for mental health service far outstrip the availability, but that
individual treatment of established disorders is an ineffective model of treatment (Barrett &
Turner, 2001), indicating a need for intervention on a much larger scale.
As populations continue to grapple with the forecasted impact of mental illness on the
economy, it is hardly surprising that interest in the prevention of mental illness has grown
markedly. In light of epidemiological research demonstrating the chronic course of anxiety
disorders which originate in childhood, preventative intervention in the formative years is
now seen as a model approach for proactively reducing the mental illness disease burden
(Bienvenu & Ginsburg, 2007; Neil & Christensen, 2009). Prevention not only assists
children with existing disorders to more adaptively manage and overcome their difficulties,
but also ‘inoculates’ non-disordered individuals against anxiety, by providing resiliency and
life-skills to more appropriately cope with future difficulties. Aside from the obvious
benefits to individuals, the timely delivery of anxiety interventions may reduce the economic
burden of these disorders through decreasing the need for costly clinical treatment once
disorders are established (Neil & Christensen, 2009; Spence & Dadds, 1996). This in turn
may relieve the pressure of high demand currently placed on already stretched mental health
services (Donovan & Spence, 2000). Further economic benefits of prevention programs for
anxiety delivered in childhood may include reduced rates of unemployment, and decreases in
lost productivity as a result of employee absences due to anxiety (Donovan & Spence, 2000).
63
Levels of Prevention
At a preliminary level, how prevention is approached and structured depends largely
on both the population in question, and the mental health issue to be addressed. These
questions must be answered in deciding which strategy to implement, with individual
advantages and disadvantages inherent to each strategy. The current framework of choice for
prevention was described in a report by the Institute of Medicine (Mrazek & Haggerty, 1994),
and has been widely used as a multi-level model of prevention for mental illness. This three-
tiered framework posits that mental illness occurs on a spectrum of symptom severity, and
that the point of intervention may occur anywhere along this spectrum. With specific regard
to prevention, it acknowledges the developmental pathways of mental disorders as a function
of risk factors, and emphasises that the reduction of risk factors prior to the onset of a
diagnosable disorder constitutes the most optimal model of intervention.
The above framework draws distinction between three different levels of prevention:
universal, selective, and indicated. Universal prevention involves the treatment of an entire
population of individuals, regardless of differences in diagnostic status or risk. The goal is to
reduce risk factors for mental illness through targeting symptoms and building resiliency,
thereby reducing both the incidence and prevalence of diagnosable disorders. An example of
universal prevention is an intervention for anxiety at a school-level, with all students
participating. By comparison, selective prevention focuses on a subset of the population who,
whilst not yet displaying symptoms of a diagnosable disorder, have existing identifiable risk
factors for mental illness. For example, given that exposure to traumatic events is a
recognised risk factor for anxiety disorders, a selective intervention for anxiety may involve
running an anxiety program for a group of children who lived through a natural disaster, such
as a bushfire. Lastly, indicated prevention is targeted at individuals already experiencing
64
clear signs or symptoms of mental illness, who are therefore at greatest risk of developing a
diagnosable disorder. As an example, an indicated intervention for SOP in youths might
focus on those children already demonstrating elevated anxiety in social situations and
demonstrating avoidance behaviours.
Each level of prevention has both strengths and weaknesses in terms of utility,
methodology, and overall outcome. A comparison of these strengths and weaknesses for
each level of prevention is presented in Table 1 below. Given that they both involve only a
subset of a whole population, indicated and selective prevention strategies share many
characteristics. From a research perspective, these intervention strategies are associated with
the greatest effect size, given that they focus exclusively on reducing rates of
psychopathology in individuals who are most at risk of disorder or who already fulfil criteria
for mental disorder (Barrett & Farrell, 2007). For this reason, indicated and selective
prevention programs may be more likely to attract funding for research. Furthermore, given
that indicated and selective prevention strategies are applied only to the percentage of the
population who stand to benefit the most, the time, costs, and resources required to
implement such an intervention are significantly less than those required for universal
prevention strategies (Donovan & Spence, 2000). Another benefit is the smaller facilitator-
to-participant ratio typical of small group interventions, which may afford participants a more
concentrated dosage of the intervention, and more individual attention. The small-group
nature of these levels of intervention also means there will likely be less participant attrition.
Whilst these strengths make indicated and selective prevention attractive options for
school-based intervention, there are limitations to these approaches. Perhaps most notably,
the recruitment of individuals requires screening to identify individuals who fulfil participant
65
criteria. The identification of children as being at risk may result in these children being
stigmatised within the school environment, which may reinforce existing emotional
difficulties. Another complication of school-based indicated and selective prevention is
timetabling, as these interventions are typically run during normal school hours.
Accordingly, there is the possibility of learning being disrupted due to classroom absences to
attend intervention groups, particularly if groups are regularly held at the same time each
week. Furthermore, unless the schools involved have sufficient additional support staff (such
as teacher aides or guidance counsellors) who can be trained to deliver the interventions,
group facilitators may be required from outside of the school community, given that regular
classroom teachers will be occupied in class with the majority of students.
Universal prevention is distinct from indicated and selective prevention, in that it is
designed to be applied to all members of a given population. Prevention of childhood anxiety
delivered at the universal level affords all children the opportunity to learn and develop skills
designed to reduce the prevalence of anxiety disorders in childhood on the widest scale
possible. Whilst children with anxiety disorders obviously benefit from the intervention, the
advantage of universal prevention is that it includes children who would not otherwise be
eligible for, or have access to, mental health services. Therefore, universal prevention
overcomes a significant barrier for many families. Furthermore, given that universal
interventions are typically conducted in the school, the inclusion of all children also avoids
the possibility of stigmatisation. Universal prevention for internalising disorders conducted
in the school setting also serves to normalise the experience of worry and sadness in children,
and provides a non-threatening and familiar milieu in to explore and practice strategies for
dealing with these emotions (Evans, 1999; Kubiszyn, 1999).
66
Despite the obvious benefits of universal prevention, interventions on a population
level can be very difficult to implement and research, due largely to the sheer number of
children involved. Universal prevention in schools requires a high degree of co-operation
from all stakeholders on a regular basis. The time and financial costs are greater than for
other levels of prevention, given the large number of children that must participate in pre,
post, and often, follow-up screening, to demonstrate program effectiveness (Barrett & Farrell,
2007). Another limitation is that universal prevention typically produces a lower effect size,
given that the group of children with clinically significant anxiety constitutes only a small
percentage of the total participant sample. Therefore, researchers may find it more difficult
to attract funding for universal prevention. Additionally, larger sample sizes generally
require a greater number of facilitators (in a school setting, these are most often teachers),
each of whom must be trained in the delivery of the intervention (Donovan & Spence, 2000).
A greater number of participants also increase the likelihood of attrition, in particular at long
term follow-up intervals. Despite these hardships, the body of research on universal
prevention in schools continues to grow, with promising findings encouraging continued
research in the field.
Table 1
Strengths and Weaknesses of Indicated, Selective and Universal approaches to School-based
Prevention
Strengths Weaknesses
Indicated School-  Larger effect sizes  Screening process involved
based Prevention  Cheaper to implement –  Risk of stigmatisation and
less materials required labelling of participants
&  Smaller numbers of group  Potential for children to
facilitators to train miss classes
Selective School-  More likely to attract  External group facilitators
based Prevention funding may be required
67
 Smaller participant groups

– higher intervention
“dosage”
 Lower ratio of children to
group leader
 More personalised –
children receive more
individual attention
 Lower attrition rates
Universal School-  All children have the  More training required for
based Prevention opportunity to develop greater number of
positive coping skills, facilitators
regardless of risk or  More expensive to deliver –
diagnostic status more materials required
 Overcomes barriers to  Smaller effect sizes due to
accessing mental health higher numbers
services for all families  Larger groups – higher ratio
 Avoids the possibility of of children to group leader
stigmatisation
 Normalises anxiety
 Can implement as part of
the curriculum
With the expansion of interest in the field of prevention, there have been several
investigations of preventative interventions for childhood anxiety at each of the three levels
discussed above. Much of this research has been conducted in the school setting, which
affords the perfect milieu for treatment of anxiety in children. Delivering mental health
services via schools overcomes many barriers to traditional community-based treatment,
including time, location and transportation difficulties, excessive cost, and stigmatisation
(Barrett & Pahl, 2006; Neil & Christensen, 2009), thereby engaging children who may not
otherwise receive treatment (Chatterji, Caffray, Crowe, Freeman, & Jensen, 2004). School-
based programs may be delivered at the indicated, selective, or universal level, with a recent
review of school-based interventions for anxiety concluding that over three-quarters of the
trials investigated effectively reduced childhood anxiety in the treatment population (Neil &
68
Christensen, 2009). The following sections will review the body of literature pertaining to
school-based programs for childhood anxiety at each intervention level, with specific focus
on the prevention on a universal level.
Indicated Prevention
A small body of published research exists for the evaluation of indicated prevention
of childhood anxiety in schools. The first study was conducted by Kiselica, Baker, Thomas,
and Reedy (1994) who evaluated a preventative stress inoculation program with a sample of
48 students in Grade 9. Participants receiving the intervention were selected for inclusion
based on elevated anxiety scores on self-report measures of trait anxiety and symptoms of
stress. The eight-session intervention, which was delivered in a classroom setting, consisted
of three components: progressive muscle relaxation, cognitive restructuring, and
assertiveness training. Compared to a matched-sample control group, participants in the
intervention group scored significantly lower on both self-report measures following the
completion of the intervention. At four weeks post-intervention, participants in the
intervention group continued to report significantly less anxiety and symptoms of stress than
control participants. This early research provided preliminary support for school-based
indicated prevention of childhood anxiety.
Later research by Dadds, Spence, Holland, Barrett, and Laurens (1997) examined the
effectiveness of a 10-session CBT intervention for the prevention of anxiety in children and
adolescents. Participants were aged between 7 and 14 years, and were selected on the basis
of sub-clinical or mild clinical levels of anxiety, as determined by child self-report, teacher
nominations, and parental interviews. The intervention protocol evaluated was the
aforementioned Coping Koala program (Barrett, Dadds et al., 1996), a CBT intervention for
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childhood anxiety with an added parental component designed to educate parents about
childhood anxiety, and provide information about concepts and strategies taught in the
program. In conjunction with the 10 weekly school-based child sessions, parents of
participants were given the opportunity to attend three parent education sessions during the
intervention phase. Significant decreases in anxiety were noted at the completion of the
program in both the intervention and the control group, however a significant preventive
effect on the diagnosis rate, child adjustment, and family adjustment, was evident at both 6
and 24-month follow-ups for the intervention group only (Dadds et al., 1999). This research
provides more evidence for the utility of indicated prevention of anxiety disorders in schools.
The above research has been strengthened by more recent replications demonstrating
the positive effects of school-based indicated interventions for anxiety. Research conducted
in the Netherlands involved the screening of 425 children aged 8 to 13 years for clinical
anxiety (Muris & Mayer, 2000, cited in Barrett & Turner, 2004). Of this sample, 42 children
with elevated anxiety scores were selected to participate in the Coping Koala program
(Barrett, Dadds et al., 1996). Whilst 86% of the students in the sample met full criteria for a
major anxiety disorder prior to the intervention, 75% of participants were diagnosis-free 6
months following the completion of the program.
Most recently, Bernstein, Layne, Egan, and Tennison (2005) compared the
effectiveness of group-based CBT, the FRIENDS for Life program (Barrett, Webster, &
Turner, 2000), when delivered alone, or with a parent training component. Children were
aged 7 to 11 years, and were identified as having elevated levels of anxiety according to
questionnaire self-report, teacher nomination, and parent and child diagnostic interviews. To
qualify for inclusion, all participants had to meet diagnostic criteria for SAD, GAD, and/or
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SOP, or demonstrate one or more diagnostic criteria of at least one of these disorders.
Significant reductions in anxiety symptoms and diagnoses were noted post-intervention in
both intervention groups, relative to a control group. In terms of change in diagnostic status,
CBT alone was shown to be superior to CBT plus parent training. However, according to
parent report of child anxiety and clinician rated severity, CBT plus parent training was
shown to be superior to CBT alone, with no significant difference between the latter and the
control group.
The above reviewed research demonstrates that school-based group CBT for
childhood anxiety is successful when delivered at the indicated level of prevention.
Regardless of whether the intervention is structured as child-only, or includes a parent
training component, school-based indicated prevention of childhood anxiety is more effective
than no treatment in reducing anxiety symptoms in children.
Selective Prevention
Several studies have investigated prevention of childhood anxiety at the selective
level. Individuals and groups have typically been recruited for participation in selective
prevention studies based on possessing one or more risk factor for anxiety. Cultural change
and migration have been recognised as risk factors for the development of anxiety (Barrett,
Turner, & Sonderegger, 2000), hence several research groups have evaluated a school-based
CBT intervention for anxiety, the FRIENDS for Life program (Barrett, Lowry-Webster, &
Holmes, 1999), in culturally diverse populations. These populations have included children
and adolescents of former-Yugoslavian, Chinese, and mixed ethnic backgrounds (Barrett,
Moore, & Sonderegger, 2000; Barrett, Sonderegger, & Sonderegger, 2001; Barrett,
Sonderegger, & Xenos, 2003). In each study, participants who received the intervention
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demonstrated significantly reduced scores on anxiety measures, relative to participants in
wait-list control groups. Significant improvements were also noted on self-esteem measures.
Promisingly, gains made by the intervention groups were maintained 6 months post-treatment
(Barrett et al., 2003). This research targeted minority groups with known risk factors for
childhood anxiety, and successfully demonstrated significant reductions in anxiety
symptomatology. This indicates that clinically significant improvements may be procured
via intervening prior to the onset of a diagnosable disorder in at-risk populations.
Exposure to community violence is another established risk factor for the
development of anxiety disorders in youth (Cooley-Quille, Boyd, Frantz, & Walsh, 2001).
Research conducted by Cooley, Boyd, and Gradas (2004) investigated the effectiveness of the
FRIENDS for Life program (Barrett et al., 1999) with a small sample of inner-city African-
American children aged 10 to 11 years. Participants were drawn from an elementary school
within a recognised low SES district, where crime rates were high. Children selected for the
intervention displayed moderate symptoms of anxiety, identified by a combination of both
child self-report and teacher nomination measures. The intervention was delivered in 11 bi-
weekly sessions during normal class time. A significant reduction in anxiety
symptomatology was noted from pre to post-intervention. The results suggest the program
was effective in reducing anxiety in this at-risk population, however long-term follow-up data
is required to determine the longitudinal effects of the intervention in populations with high
exposure to community violence.
Another significant risk factor for childhood anxiety is socioeconomic disadvantage
(Buka, Monuteaux, & Felton, 2002), which is of central importance to the current research.
In an evaluation of selective intervention using a CBT-based program for childhood anxiety
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delivered in nine socioeconomically disadvantaged schools, Misfud and Rapee (2005)
reported significant decreases in anxiety symptoms post-treatment and at 4 months follow-up.
This study is unique, in that it is one of only two evaluations of childhood anxiety
intervention programs conducted specifically within a disadvantaged community. Further
details of this study, and a more thorough discussion of the relationship between
socioeconomic disadvantage and childhood psychopathology will be discussed in Chapter 5.
Universal Prevention
There has been a notable surge in research into school-based universal prevention of
anxiety over the last decade, with growing recognition of schools as the ideal platform for the
simultaneous delivery of interventions to large numbers of children (Masia-Warner, Nangle,
& Hansen, 2006; Neil & Christensen, 2009). The results of anxiety intervention and
prevention programs delivered in schools at the universal level have been largely positive,
with 69% of universal trials evaluated in a recent review reporting significant reductions in
anxiety for children in the intervention condition (Neil & Christensen, 2009). Whilst a
number of different intervention protocols have been researched, with several reporting
significant positive effects (Berger, Pat-Horenczyk, & Gelkopf, 2007; Garaigordobil, 2004;
Hains, 1992; Hains & Ellmann, 1994; Hains & Szyjakowski, 1990), by and large the most
extensively researched intervention program for childhood anxiety delivered universally is
the FRIENDS program. Accordingly, and given that the current research is concerned with
further evaluation of this program, the following section reviews empirical evidence detailing
the universal implementation of the FRIENDS program in schools.
The first published research in this area was conducted by Barrett and Turner, (2001),
who evaluated the effectiveness of the FRIENDS for Children program (Barrett et al., 1999)
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when delivered as a universal prevention program to 489 Grade 6 children (aged 10 to 12
years) across 10 primary schools in Brisbane, Australia. Importantly, this research also
evaluated a “train-the-trainer” model of intervention, with the schools allocated to one of
three conditions: (a) psychologist led intervention (n = 188), (b) teacher led intervention (n =
263), and (c) standard curriculum with monitoring (n = 137). All teachers and psychologists
facilitated the intervention groups received intensive training in the program delivery, and
parents of children in both intervention groups were invited to attend four parent evenings
incorporating psychoeducation and parenting strategies. Screening for internalising
symptomatology included three self-report questionnaires completed within normal class
time. Evaluation of these measures post-intervention showed that children in both
intervention groups reported significantly fewer anxiety symptoms, relative to the monitoring
condition. These promising results provided early support for the effectiveness of the
FRIENDS program when delivered as a school-based universal prevention for anxiety,
regardless of whether the program was delivered by teachers or psychologists. More recent
support for teacher-led anxiety interventions has been reported by Neil and Christensen
(2009), who found that a higher percentage of trials with teachers as program leaders resulted
in significant reductions in anxiety, when compared to programs led by mental health
professionals, researchers, and graduate students.
A subsequent study also investigated the effectiveness of FRIENDS for Children
(Barrett, Webster et al., 2000) as a universal intervention with a slightly older population of
school-aged children (Lowry-Webster, Barrett, & Dadds, 2001). A total of 594 children in
Grades 5 to 7 (aged 10 to 13 years) from seven private Catholic schools in Brisbane,
Australia, were assigned to either the intervention or monitoring-only condition, with all
children screened using self-report measures of anxiety and depressive symptomatology. The
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intervention was facilitated by teachers trained to deliver the program, and was implemented
in 10 weekly sessions during regular classroom time. Following the conclusion of the
program both the intervention and control group demonstrated significant reductions in self-
reported anxiety symptoms, however these reductions were significantly greater for the
intervention group. Only the intervention group showed a significant reduction in depressive
symptoms post-intervention.
The above study also investigated changes in risk status for anxiety. Children were
identified as being at high risk for anxiety if their pre-intervention scores fell above the
clinical cut-off on the self-report anxiety measure. It was found that 75.3% of high-risk
children in the intervention condition were no longer at risk post-intervention, compared to
54.8% of high-risk children in the control condition (Lowry-Webster et al., 2001).
Longitudinal effects of the intervention were later investigated in a 12-month follow-up study
(Lowry-Webster, Barrett, & Lock, 2003). The positive gains made by children in the
intervention condition were maintained, with this group demonstrating significantly lower
anxiety scores than children in the control condition. Further investigation with children
previously identified as high-risk was conducted through diagnostic interviewing, revealing
that 85% of high-risk children from the intervention group were diagnosis free 12 months
following the intervention, compared to 31% of high-risk children from the control group.
This research further demonstrates the effectiveness of the FRIENDS program in preventing
anxiety symptoms when delivered as part of the school curriculum, and points to its
continued effectiveness over time.
Another longitudinal study of a universal school-based application of the FRIENDS
program was conducted by Lock and Barrett (2003), to determine whether the program was
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more effective when implemented in late primary, or early secondary school. Participants
included Grade 6 (n = 336; aged 9 to 10 years) and Grade 9 (n = 401; aged 14 to 16 years)
students from seven schools in Brisbane, Australia, of ranging socioeconomic diversity.
Participants were assigned to either the intervention or control condition (standard
curriculum), based on the school they attended, and all students completed self-report
measures on anxiety and coping. As with previous research (Lowry-Webster et al., 2001;
Lowry-Webster et al., 2003) risk group status was determined by scores on self-report
measures of anxiety. Consistent with the existing literature (Lowry-Webster et al., 2001;
Lowry-Webster et al., 2003), participants in the intervention conditions showed greater
reductions in anxiety symptomatology both post-treatment and at 12 months follow-up. With
regards to age differences, the Grade 6 group reported higher levels of anxiety both pre and
post-intervention than the Grade 9 group, however the younger group reported significantly
less anxiety symptoms at 12 months follow-up, suggesting that late primary school may be
the optimal time for anxiety prevention programs to be implemented in school. Similarly, a
subsequent longitudinal study investigating developmental differences in universal school-
based prevention of anxiety also concluded that intervention with children in younger grades
may be associated with more significant reductions in anxiety (Barrett, Lock, & Farrell,
2005).
In recent years, more extensive longitudinal research has been conducted with Lock
and Barrett's (2003) original sample, to determine the long-term effectiveness of the
FRIENDS program when delivered as a universal, school-based intervention (Barrett, Farrell,
Ollendick, & Dadds, 2006). The follow-up research investigated outcomes at 24 months
(Grade 8 and Grade 11) and 36 months (Grade 9 and Grade 12) post-intervention. Based on
self-report measures of anxiety, the original intervention gains were maintained for the
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younger intervention group, with significantly lower ratings of anxiety at long-term follow-
up. By comparison, there were no significant differences in anxiety ratings for the older
intervention group across all follow-up time points. As with the earlier research (Lock &
Barrett, 2003), these findings appear to indicate that universal school-based anxiety
prevention may be most effective in reducing anxiety when delivered during late primary
school. With regards to risk group status at long-term follow-up, whilst there was no
significant difference between the intervention condition and control condition at the 24
month time-point, by 36 months, participants in the intervention groups were significantly
less likely to fall within the at-risk range (12%) relative to those in the control group (31%).
Overall, this research provides further promising support for the implementation of school-
based universal prevention programs for anxiety, particularly if delivered in late primary
school, and demonstrates that positive intervention effects are robust up to 3 years post-
intervention.
Whilst FRIENDS has been well validated as a universal intervention for anxiety
within Australian schools, the most recent evaluation of the program delivered as a universal
school-based intervention was conducted in the United Kingdom (Stallard, Simpson,
Anderson, Hibbert, & Osborn, 2007). Participants were 106 children (aged from 9 to 10
years) from three primary schools, including one school from a socially deprived region. All
participants completed self-report questionnaires to determine anxiety symptomatology and
levels of self-esteem 6 months prior to commencing the program, immediately before the
intervention, and 3 months post-intervention. School nurses were trained to deliver the
program, which was delivered over 10 weekly sessions during normal class time. Parents
were also invited to attend a psychoeducation session at the start of the program, detailing the
contents of the intervention. Results demonstrated significant increases in self-esteem and
significant reductions in self-reported anxiety symptoms from 6 months prior to intervention
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to 3 months post-intervention. Stallard et al. (2007) also investigated treatment effects
specifically within the high-risk group. In this group, children reported significantly less
anxiety at 3 months post-treatment, than at both 6 months prior to treatment, and immediately
before treatment.
The above research was furthered more recently in a 12-month follow-up study
(Stallard, Simpson, Anderson, & Goddard, 2008). Results demonstrated that the positive
effects of the intervention at 3 months follow-up were maintained 12 months post-treatment
(Stallard et al., 2007), with no difference between 3 month and 12 month follow-up scores on
self-reported anxiety and self-esteem. Similarly, there was no difference in anxiety scores for
children in the high risk group, from 3 months to 12 months follow-up, demonstrating the
effects of the intervention were robust for the most highly anxious participants. Further to
this, 67% of children who were identified as high risk at baseline had moved into the low risk
group at 12 months post-intervention. It is worth noting the smaller sample size in this
research in comparison to the aforementioned studies, and that this research was affected by
attrition of 59% of the original sample size by 12-months follow-up. This research also
deviated from the previous literature in that it did not include a control group for comparison.
These issues not-withstanding, the results of this research demonstrate further evidence for
the effectiveness of the FRIENDS program as a universal school-based intervention for
anxiety, and compliment the existing literature in this area.
Summary
The body of literature reviewed above provides a strong evidence base for the
effectiveness of universal interventions for anxiety when delivered in a school setting. Most
studies to date have evaluated the FRIENDS program, extending on the existing body of
empirical research validating this program for use with groups in both a clinic and a school
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setting (Barrett, Dadds et al., 1996; Barrett, Moore et al., 2000; Barrett, Sonderegger et al.,
2001; Barrett et al., 2003; Bernstein et al., 2005; Cooley et al., 2004; Dadds et al., 1999;
Dadds et al., 1997). The research clearly demonstrates the effectiveness of the program in
reducing rates of anxiety at post-intervention (Barrett & Turner, 2001; Lock & Barrett, 2003;
Lowry-Webster et al., 2001; Stallard et al., 2007), 12 month (Lock & Barrett, 2003; Lowry-
Webster et al., 2003; Stallard et al., 2008), 24 month and 36 month follow-up assessments
(Barrett et al., 2006). These impressive results, along with findings that the program is just as
effective when delivered by trained school staff as when delivered by psychologists (Barrett
& Turner, 2001), and it’s flexibility to be implemented as part of the standard school
curriculum, suggest this program is an ideal choice for school-based anxiety prevention.
It is worth noting that the research reviewed above has been conducted almost
exclusively within private schools, or public schools within middle to upper class
socioeconomic populations. It is acknowledged that a handful of researchers have attempted
to involved schools along the spectrum of socio-economic advantage (Barrett & Turner,
2001; Stallard et al., 2007; Stallard et al., 2008). Unfortunately however, these studies did
not explicitly report outcomes on a school-by-school basis, missing the opportunity to
specifically investigate program efficacy within disadvantaged schools. To date, only two
studies investigating the efficacy of school-based anxiety prevention in disadvantaged
communities have been published (Misfud & Rapee, 2005; Roberts et al., 2010). The latter
study, which used an alternative protocol to the FRIENDS for Life program, is notable in that
it is the only published evaluation of a universal school-based intervention program for
childhood anxiety carried out within socioeconomically disadvantaged schools. This study
will be discussed in more detail in the following chapter.
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By and large, schools in socioeconomically deprived areas have been ignored as
potential research sites, resulting in a significant gap in the literature on school-based
prevention of anxiety. The current research will attempt to fill this gap in the literature, by
evaluating the delivery of a universal intervention for childhood anxiety in three schools
within a region recognised as socioeconomically disadvantaged. The issue of childhood
anxiety in low SES communities will now be discussed.
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CHAPTER FIVE: CHILDHOOD ANXIETY IN DISADVANTAGED COMMUNITIES
A link between socioeconomic status (SES) and mental illness has long been
recognised. Ever since an early study demonstrated the significant inverse relationship
between rates of schizophrenia and SES (Faris & Dunham, 1939), research has established
that adults and children from socioeconomically disadvantaged communities are at an
increased risk for psychopathology and a range of other negative health and psychosocial
outcomes (Buckner & Bassuk, 1997; Buka et al., 2002; Curtis et al., 2001; McLeod &
Shanahan, 1993). Psychiatric disorders and psychological distress are more prevalent in
adults with low income (Bruce, Takeuchi, & Leaf, 1991; Kessler, 1982), whilst children and
adolescents from poor families are significantly more likely to be in the clinical or sub-
clinical range for a range of emotional and behavioural problems (Sawyer et al., 2001).
Longitudinal research with children has found that low income predicted internalising
problems, as well as externalising difficulties, and social, attentional and thought problems,
as early as five years of age (Bor et al., 1997), whilst female adolescents whose families lived
in poverty for the first five years of their lives have been found to report greater symptoms of
anxiety and depression (Spence, Najman, Bor, O'Callaghan, & Williams, 2002). The link
between low SES and poor psychosocial outcomes is evident at the community level, and the
significant effects of community factors upon child outcomes have been demonstrated even
after controlling for personal and family characteristics (Brooks-Gunn, Duncan, & Aber,
1997; Buck, 2001; Coleman, 1988; Drukker et al., 2003) (Caspi, Taylor, Moffitt, & Plomin,
2000).
The following section reviews the link between socioeconomic disadvantage and
psychopathology, focusing specifically on research with children where available. It
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discusses the magnitude of the problem of psychiatric disorders in low SES populations, and
examines barriers to mental health services commonly faced by families from disadvantaged
communities. The research reviewed supports the argument for universal intervention for
anxiety specifically within these high-risk communities, providing a rationale for the current
study.
Prevalence of Childhood Psychopathology in Disadvantaged Communities
There is a robust relationship between low SES and childhood psychopathology. In
the Great Smoky Mountains Study of Youth (Costello et al., 1996), a large-scale population-
based study investigating the need, utilisation, and development of mental health services for
children and adolescents, it was found that children of families below the poverty line were
three times more likely to meet criteria for any disorder, and every individual diagnosis
except tic disorder. More recent research, based on data collected from the Project on
Human Development in Chicago Neighborhoods, investigated levels of internalising
problems (depression, anxiety, withdrawal, and somatic problems) in 2800 children aged
between 5 and 11 years (Xue, Leventhal, Brooks-Gunn, & Earls, 2005). Significant
differences were found between neighbourhoods identified as being of low, medium, and
high SES, with 21.5%, 18.3%, and 11.5% of children ranking above clinical threshold levels
in each neighbourhood category respectively. These findings indicate the inverse relationship
between SES and internalising problems in children, demonstrating an increased risk of such
problems in conjunction with decreases in SES.
The link between SES and anxiety has also been investigated more specifically,
though research including younger populations has tended to focus on adolescents and young
adults, rather than children. Given the chronic course of anxiety however, and the tendency
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of childhood anxiety to persist well into adolescence and adulthood, a review of this literature
is very relevant. Research by Kessler et al. (1994) investigated lifetime and 12-month
prevalence rates of DSM-III-R (American Psychiatric Association, 1987) psychiatric
disorders across several age ranges, including adolescents and early adults aged from 15 to 24
years. Anxiety disorders were significantly overrepresented in individuals from the lowest
income bracket, in terms of both 12 month and lifetime prevalence. Another interesting
finding was that low SES was more strongly related to anxiety disorders than to affective
disorders, suggesting that lower social status may exacerbate worries and stresses more so
than sadness (Kessler et al., 1994). More recently, Miech, Caspi, Moffitt, Entner Wright, and
Silva (1999) conducted a large-scale longitudinal study based on data from a Dunedin birth
cohort, which assessed the mental health of 1037 youths at ages 15 and 21. Consistent with
Kessler et al.'s (1994) research, it was found that anxiety disorders were disproportionately
represented in families of lower SES.
There remains some contention regarding the direction of the relationship between
SES and mental illness, with researchers generally adopting one of two contrasting
theoretical viewpoints (Buka et al., 2002). The selection perspective holds that individuals
with existing psychiatric disorders become disadvantaged as a result of downward mobility in
social class, resulting in the overrepresentation of mental disorders in lower socioeconomic
strata. By comparison, the causation perspective posits that low SES contributes to the
development of psychopathology through a range of mechanisms, such as stress,
occupational limitations, and poor social and psychological coping resources (Buka et al.,
2002; Miech et al., 1999). The differential effects of each process are difficult to disentangle,
though research to date points that SES is differentially related to mental illness according to
the type of disorder (Dohrenwend et al., 1992).
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There have been concerted efforts by researchers to determine whether selection
theory or causation theory best explains the correlation between low SES and high anxiety.
Miech et al. (1999) attempted to unravel the differential effects of causation and selection
through investigating temporal differences in anxiety in relation to educational attainment, a
variable associated with SES, in adolescents and young adults. By age 21, it was found that
individuals with low educational attainment reported significantly higher levels of anxiety,
and that increases in anxiety between the ages of 15 and 21 were highest in participants with
low educational credentials (Miech et al., 1999). This was taken to support the utility of
causation theory - that low SES contributes to the development of psychopathology, in
explaining the link between SES and anxiety disorders.
Neighbourhood Effects of Socioeconomic Disadvantage on Childhood Anxiety
If indeed socioeconomic disadvantage precipitates anxiety and other
psychopathologies in children, it is useful to understand the factors which may contribute to
this situation. There is considerable evidence that a shared social environment imparts
significant effects on the psychological health and wellbeing of its residents, above and
beyond their individual risk profile (Coleman, 1988; Driessen, Gunther, & Van Os, 1998;
Kalff et al., 2001; Van Os, Driessen, Gunther, & Delespaul, 2000). Not surprisingly then, the
overrepresentation of psychopathology in disadvantaged communities has been explained as
a function of the characteristics of shared environments. Jencks and Mayer (1990) endorsed
4 models designed to explain how community factors may affect childhood wellbeing in
disadvantaged communities. The contagion model highlights the role of peers in influencing
a child’s behavioural outcome. The theory of collective socialisation, stipulates that child
outcomes are affected by the availability of positive adult role models, and their vigilance in
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monitoring the child’s behaviour. The competition model holds that outcomes are influenced
by the degree of opportunities (such as employment and education) available to the
community. Lastly, the relative deprivation model refers to discontent experienced by
members of a community when they compare their own situation to that of others in the
community who are more fortunate. These models explore the elements of a physical
community that may be implicated in mental health outcomes at an individual level.
Later, Macintyre, MacIver, and Sooman, (1993) also discussed categories of shared
community environmental variables that are implicated in the effect of neighbourhood
socioeconomic status on population mental health. The five categories of variables identified
were (1) shared physical features (e.g. quality of air or water), (2) availability of healthy
work, school, home and play environments (e.g., decent housing, secure environments), (3)
public/private services available to support residents (e.g. education, transport, health and
welfare services), (4) socio-cultural factors (e.g. crime, community support networks) and (5)
neighbourhood reputation (how the region is perceived). These variables differ widely along
the socioeconomic spectrum (Macintyre, Ellaway, & Cummins, 2002). More recently, Ellen
and Turner (1997) also identified a set of neighbourhood factors focusing on social
connections within communities and characteristics of the community itself. These included:
(1) socialisation by adults, (2) local social networks, (3) peer influences, (4) quality of local
services, (5) exposure to crime and violence, and (6) isolation from economic opportunities.
These models share a common element: they use the interaction of socioeconomic factors and
infrastructural and social variables to explain the production of a social condition associated
with an overall lower quality of life, thereby impacting mental health at a community level.
Each of the models described above points to the social elements of a community
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which may compromise the wellbeing of its citizens. These elements may be conceptualised
collectively under the concept of social capital, which in its simplest form refers to the quality
of connections within and between social networks (Coleman, 1988). Putnam (1993) later
expanded on this definition, to include community networks, civic engagement, sense of
belonging, cohesion of a community, reciprocity and cooperation, and community trust.
Social capital may be fostered and transferred through institutions that form social structures
designed to establish social bonds, such as families, schools, community groups, and
neighbourhoods in general (McKenzie, Whitley, & Weich, 2002). In regions of higher SES,
social capital manifests through more frequent and higher quality interaction between
members of the community, at a family, school, and neighbourhood level (Coleman, 1988),
contributing to a more supportive environment and leading to more positive mental health
outcomes.
By comparison, increased income inequality, a key indicator of differences in SES, is
thought to contribute to lower levels of social cohesion, trust, social control and trust, which
are key components of social capital (Aneshensel & Sucoff, 1996; Kawachi, Kennedy, &
Wilkinson, 1999; Sampson, Morenoff, & Earls, 1999; Whitley & McKenzie, 2005). Low
social capital is a neighbourhood factor that has been associated with an increased risk of
poor mental health outcomes (Coleman, 1988; Kawachi et al., 1999; Sampson et al., 1999), as
well as low neighbourhood socioeconomic status itself (Driessen et al., 1998; Kalff et al.,
2001). An inverse correlation exists between social capital and SES, such that lower levels of
social capital are predictive of higher levels of socioeconomic deprivation (Drukker et al.,
2003; van der Linden, Drukker, Gunther, Feron, & van Os, 2003; Warner & Rountree, 1997).
This interaction may provide the perfect conditions for the development of higher rates of
mental illness at a community level. With regards to internalising disorders, several studies
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have demonstrated significant correlations between low social capital and social cohesion,
and anxiety and depressive symptomatology (Aneshensel & Sucoff, 1996; McCulloch, 2001;
Phongsaven, Chey, Bauman, Brooks, & Silove, 2006; Yen & Kaplan, 1999), though a recent
review concluded that this relationship is somewhat inconsistent (Whitley & McKenzie,
2005). Regardless of this inconsistency, the above evidence suggests that neighbourhood
effects on mental health are very real, and likely play a significant role in the development of
anxiety in children, particularly in socioeconomically disadvantaged communities.
In short, the research reviewed above indicates that there are clear negative effects at
the individual level of living within a disadvantaged neighbourhood, providing further
impetus for intervention specifically within these needy and high risk communities.
Barriers to Mental Health Service Utilisation in Disadvantaged Communities
Despite the fact that higher rates of mental illness are found in socioeconomically
disadvantaged communities, the utilisation of mental health services in these regions does not
correspond to this increased prevalence. Indeed, children with psychopathology from
disadvantaged communities are not only less likely than other children to receive treatment
(Cunningham & Frieman, 1996; Kazdin & Mazurick, 1994; Kazdin & Wassell, 1999; Misfud
& Rapee, 2005; Snell-Johns et al., 2004), but they are also more likely to disengage from
treatment before achieving positive treatment outcomes (Gonzales, 2005; Harrison, McKay,
& Bannon, 2004; Kazdin, Holland, & Crowley, 1997). An explanation for why children from
poor families do not receive the treatment they so desperately require necessitates the
examination of barriers to mental health service utilisation in these populations. In an
investigation of barriers hindering access to child mental health services in general, Owens et
al. (2002) identified three discreet categories of barriers: (1) structural barriers, (2) barriers
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related to perceptions about mental health problems and (3) barriers related to perceptions
about mental health services. Each category will be discussed below, within the context of
socioeconomically disadvantaged populations.
Structural barriers may be described as any factors inherent to either the specific
family structure, or the mental health service structure, which may prevent an individual from
accessing an appropriate mental health service. In many cases, these barriers prevent families
from engaging with services when they have an express desire to do so. In an investigation
of mental health service usage in homeless youths and young people from low income
families, Buckner and Bassuk (1997) identified several family characteristics which may act
as structural barriers to accessing mental health services in disadvantaged communities. Lack
of social support, particularly in single-parent families, may act as a significant barrier via
placing practical and economic constraints on the parent’s time and resources (Harrison et al.,
2004). Buckner and Bassuk (1997) also identified the role of pragmatic constraints for low
income families, such as lacking transport and child care options, and competing financial
priorities such as food or accommodation, resulting in inability to pay for services. In terms
of service structure barriers, factors such as a lack of availability of providers and increased
wait times for treatment have been cited (Owens et al., 2002), due largely to the inability of
community mental health facilities to meet increasing demand for services (Donovan &
Spence, 2000). Unfortunately then, timely intervention may only be available via costly
treatment in a private setting, which is beyond the financial means of most families in
disadvantaged settings.
The perceptions of parents, teachers, and health care providers about mental illness in
children may also pose a significant barrier to accessing child-appropriate mental health
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services. Parents and teachers in particular may have a poor understanding of the signs and
symptoms of mental illness in children, leaving them ill-equipped to identify the need for
assistance (Buckner & Bassuk, 1997; Owens et al., 2002). This is even more pertinent in the
case of childhood internalising disorders such as anxiety; internalising symptomatology may
be less identifiable in a classroom setting, where children exhibiting externalising behaviours
typically attract greater attention from teaching staff (Silverman & Treffers, 2001). Even
where an issue of concern is recognised, treatment may not be sought due to the belief that
difficulties will remit independently of intervention, leaving the child to suffer in silence.
Other perceptual barriers which may discourage service utilisation include the family being
daunted by the complexities of the referral and admission process, or perhaps more simply, a
lack of knowledge and understanding on how best to access and use the services and
resources available (Koroloff, Elliott, Koren, & Friesen, 1996).
Lastly, mental health service utilisation may be compromised by barriers related to
perceptions about these services. Parents and caregivers who do not trust mental health
services may be less likely to engage with these services for their child (Owens et al., 2002).
Where families do engage, this mistrust is likely to compromise not only the relationship
between the parent/caregiver and therapist, but also the parent/caregiver’s perceptions of
treatment relevance and effectiveness, which may result in early termination (Kazdin et al.,
1997). Another perceptual factor implicated in the underutilisation of child mental health
services is the stigma of mental illness. Despite acknowledging their child’s psychological
difficulties, parents may be apprehensive about seeking treatment both for fear of being
blamed, and concern that their child may be labelled and stigmatised (Gonzales, 2005).
Lastly, previous negative experiences with mental health services may inhibit future help-
seeking behaviours by disadvantaged families (Kerkorian, McKay, & Bannon, 2006; Owens
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et al., 2002).
Breaking Down the Barriers: School-based Prevention of Anxiety
It is now clear that the community mental health model does not appear to be working
for families from socioeconomically disadvantaged communities. Despite the increased need
for services, the significant barriers to accessing services mean that these children either do
not receive the treatment they require, or may terminate prematurely. Hence the challenge
has been to develop a model of service delivery which overcomes as many of these barriers
as possible, whilst still providing a service which produces meaningful changes in mental
health outcomes for disadvantaged populations. Currently, that model is school-based
prevention. The school is an ideal access point to large numbers of children simultaneously,
whilst affording an excellent milieu for the population-based delivery of effective
interventions for several mental health issues (Misfud & Rapee, 2005). The school setting
has been used extensively and successfully in the past for brief interventions regarding
psychosocial issues pertinent to young people, such as substance use, unprotected sex,
violence, and depression (Gonzales, 2005; Hutchinson & Poole, 1998), as well as for health
promotion (Bond, Glover, Godfrey, Butler, & Patton, 2001) and the delivery of ongoing
mental health services (Weist, Sander, Axelrod-Lowie, & Christodulu, 2002).
School-based intervention, particularly when delivered in a universal format,
effectively neutralises many pragmatic and perceptual barriers to accessing traditional
community-based mental health services for children. Given that these barriers are typically
greater in socioeconomically disadvantaged communities, this intervention model is perhaps
especially suited to these populations. Firstly, given that the intervention is delivered as part
of the school curriculum during regular class time, barriers such as transportation and child
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care difficulties are effectively eradicated (Neil & Christensen, 2009). Universal school-
based intervention also alleviates service structure barriers through a more efficient delivery
model, relieving the pressure on inundated community mental health services. Furthermore,
universal school-based intervention overcomes the barrier of anxious children not being
correctly identified as requiring treatment (Owens et al., 2002), given that all children,
regardless of risk profile, receive the intervention. School-based programs also reduces the
stigma attached to treatment for mental illness (Armbruster, 2002), which has been identified
as a significant barrier to traditional service utilisation (Gonzales, 2005). In this way,
universal school-based interventions normalise the experience of anxiety for children and
their families, by delivering services in a supportive, non-threatening, and familiar
environment.
School-Based Prevention of Childhood Anxiety in Low SES Communities
Universal school-based interventions for anxiety have been extensively researched
and evaluated for the past decade (see Chapter 4: Universal Prevention), with a wealth of
research establishing their effectiveness in significantly reducing anxiety in children and
adolescents (see Neil and Christensen, 2009, for a review). However, as addressed in the
previous chapter, research which exclusively evaluates school-based interventions for anxiety
in regions of socioeconomic disadvantage is almost non-existent. This gap in the literature is
alarming, given that these communities are at greater risk of anxiety psychopathology. To
the best of the author’s knowledge, only two studies have focused exclusively on the school-
based prevention of childhood anxiety in disadvantaged communities, at any level of
prevention. Both of these studies have been conducted in Australia, and will be discussed
below.
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The first study, conducted by Misfud and Rapee (2005), evaluated a school-based
CBT intervention for anxiety delivered at the selective level of prevention. The study
involved nine schools in Western Sydney, Australia, which were selected due to their high
concentration of socioeconomically disadvantaged families (Misfud & Rapee, 2005). From
an initial large scale screening process, 91 children (8 to 11 years) were selected for inclusion
based on elevated anxiety symptoms, as determined by child self-report and teacher
nomination. Children from five schools were allocated to the treatment condition, and those
from the remaining four schools comprised the wait-list control group. The intervention
delivered was based on the school version of the Cool Kids program (Lyneham, Abbott,
Wignall, & Rapee, 2003; Rapee, Wignall, Hudson, & Schniering, 2000), a CBT program for
the prevention of childhood anxiety. Program components included psychoeducation about
anxiety, cognitive restructuring, exposure hierarchies for feared stimuli, social skills,
assertiveness training, and coping with teasing. The program was delivered in eight weekly
sessions during normal school time, which were supplemented by two parent information
sessions. At the conclusion of the program, participants in the intervention condition
demonstrated significant decreases in anxiety symptoms relative to the wait-list control
group, both on self-report and teacher report measures, with positive gains maintained at 4
months follow-up (Misfud & Rapee, 2005).
The second, more recent study was conducted by Roberts et al., (2010), and to date is
the only published study investigating universal school-based prevention of anxiety
exclusively in disadvantaged schools. This study involved 496 students in Grade 7 (aged 11
to 13 years) from 12 public primary schools in Perth, Western Australia, which were selected
based on the Census Index of Relative Socioeconomic Status, generated by the Australian
Bureau of Statistics. Half of the schools were randomly allocated to the intervention
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condition and the other half to a control condition. Internalising symptoms were measured
using both child report and parent report questionnaires. The intervention delivered was the
Aussie Optimism Program. This program includes two components: Social Life Skills (SLS;
Roberts, Ballantyne, & van der Klift, 2003), designed to assist children with deficits in social
skills and social problem solving, low social support, and friendship difficulties, and
Optimistic Thinking Skills (OTS; Roberts et al., 2003) which focuses on reducing negative
cognitive elements such as pessimistic attribution style, negative self perceptions and future
expectations. The program was delivered by school teachers as a series of 60-minute lessons
over a 20-week period. Control group participants received 20 regular health education
lessons relating to self-management and interpersonal skills during this period.
The results of the above study were mixed. Based on child-report measures of
anxiety and depression, there were no significant differences in anxiety and depressive
symptomatology between the intervention and control groups post-intervention, or at the 6-
month or 18-month follow-up time points. Based on child-report measures, it appeared that
the intervention had no effect on levels of anxiety and depression. Some positive results were
found however in the comparison of parent-reported measures, which were inconsistent with
child-reported data. More specifically, parents of children in the intervention group reported
significant decreases in internalising symptoms post-treatment, relative to parents of children
in the control condition. Despite these positive findings, unfortunately the gains made by the
intervention group were not maintained over time; these between-group differences had
disappeared by 6 months follow-up, and there was no significant difference in parent-
reported internalising symptoms between the intervention and control groups at 18 months
post-intervention (Roberts et al., 2010). The results indicate that the intervention may have
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resulted in some improvements in child anxiety symptoms in the short term, but that it was
largely ineffective in reducing childhood anxiety in the longer term.
The above two studies are significant in that they go some way towards addressing a
neglected area of research, through addressing anxiety prevention in low SES communities.
In this sense, these studies are innovative, and both have several strengths. In both studies,
the inclusion of a no-treatment comparison group (Misfud & Rapee, 2005), and an
alternative, non-active program (Roberts et al., 2010) allowed for more conclusive analysis of
potential significant effects of the intervention. The study by Misfud and Rapee (2005) also
indicated that a more brief CBT intervention (8 sessions, as compared to the FRIENDS for
Life 10 sessions) may significantly reduce anxiety in children with elevated symptoms. This
is useful information, given that some school terms are only brief, and may only be able to
accommodate eight weekly intervention sessions. An obvious strength in the study by
Roberts et al. (2010) lies in it’s sample size, with almost 500 students across 12 different
schools involved. Additionally, this study employed a more intensive follow-up schedule,
with data collected at both 6 months and 18 months post-intervention. This is quite
impressive, given that students from the original sample would have transitioned to high
school by the final follow-up time-point. An additional strength is that this study employs
not only child self-report questionnaires, but also parental report questionnaires, providing a
collateral measure of emotional functioning. Furthermore, the inclusion of a measure
assessing child-reported social skills enabled this study to examine any potential changes in
this aspect of functioning post-intervention.
Whilst these two studies are innovative, neither is without limitations. A key
limitation of the study by Misfud and Rapee (2005) is that it employs a selective prevention
model, rather than a universal prevention model. It is already well established that selective
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group-based intervention is effective for those at risk for anxiety. What is not known is
whether a less concentrated ‘dosage’ of an intervention (such that would be delivered in a
universal intervention) is sufficient, given the larger proportion of mental illness in
disadvantaged populations. An additional limitation is that the question of potential long-
term gains associated with the chosen intervention remains unanswered. It would be
interesting to determine whether treatment gains were maintained beyond 4 months follow-
up, especially given that this sample was comprised of children with existing elevated anxiety
symptoms. It is also noteworthy that this research evaluated an alternative anxiety prevention
program to the FRIENDS for Life program. Whilst both programs are based upon a CBT
framework, which is identified as the gold standard for childhood anxiety treatment,
FRIENDS for Life has been more extensively researched. This broad and ever-growing
FRIENDS evidence base provides empirical support for the effectiveness of the program
across a range of different settings and populations, therefore affording greater opportunities
for comparison of outcomes with more current research.
The more recent study by Roberts et al. (2010) is somewhat more ambitious in it’s
scope, but the impact of this research is unfortunately compromised by inconsistent results.
Even so, despite the lack of significant self-reported reductions in anxiety and depression for
children receiving the intervention, the significant decrease in internalising symptoms
reported by parents does offer some promise for future research. Another limitation is that
this study only includes children from Grade 7, preventing the examination of any possible
effects of age or grade on intervention effectiveness. As with the research conducted by
Misfud and Rapee (2005), Roberts et al. (2010) evaluate the effectiveness of an alternative
intervention to the FRIENDS for Life program, the Aussie Optimism Program. A key point
here is the authors’ acknowledgement that the program evaluated lacks empirical evidence
95
demonstrating it’s efficacy as a treatment for anxiety and depression, both over the short term
and the long term (Roberts et al., 2010), irrespective of participants’ socioeconomic status.
Given that the authors stated that the Aussie Optimism Program is designed to target students
attending schools in low socioeconomic areas, the failure to achieve more significant results
suggests that perhaps this program is not best suited for implementation in these areas.
Therefore, it remains to be seen whether a more empirically validated program, such as
FRIENDS for Life, may deliver the more consistent, predicted changes that the above
research failed to demonstrate.
The above review of the literature on the prevention of childhood anxiety in
socioeconomically disadvantaged communities highlights several issues. Firstly, prevention
of childhood anxiety in disadvantaged schools is a significantly neglected field of research,
both within Australia and internationally. Secondly, the results yielded by the few studies
conducted in this field to date suggest that intervention within these populations may result in
clinically significant decreases in anxiety, highlighting the need for future research in the
area. Furthermore, given that research to date has been conducted using two less empirically
validated interventions for anxiety, research evaluating an alternative, more extensively
validated program for childhood anxiety is highly warranted. The current study is structured
to address this gap in the literature, and it will be discussed more extensively in the following
section.
The Current Study
A review of the available literature indicates that anxiety is a significant childhood
mental health problem, and despite the magnitude of this problem, the majority of children
will unfortunately not receive treatment (Hirschfeld et al., 1997; Sawyer et al., 2000). This
fact takes on new significance in the context regions of low SES, given that the risk for
96
anxiety disorders is magnified for residents of these regions (Sawyer et al., 2001). When
taken together with the knowledge that disadvantaged families face significant barriers to
accessing mental health services for children (Owens et al., 2002), universal school-based
prevention programs appear to be the most practical and logical option to provide timely
treatment to children who need it most. Whilst considerable evidence points to the
effectiveness of such school-based programs in reducing anxiety in children and adolescents
(Neil & Christensen, 2009), to date, research specifically with disadvantaged populations has
been slim. The available evidence suggests that such programs may be effective (Misfud &
Rapee, 2005; Roberts et al., 2010), however further research with more empirically validated
anxiety prevention programs is desperately required.
This study constitutes the first ever evaluation of a universal school-based prevention
program for childhood anxiety in disadvantaged schools using the FRIENDS for Life
program, an effective intervention for childhood anxiety that has been validated across all
three levels of prevention. This research encompassed students in Grades 5, 6, and 7, from
three public primary schools within Queensland, Australia. This age-group was selected
based on the finding that the upper primary school years provide an ideal window for the
prevention of internalising disorders in children (Barrett et al., 2006; Lock & Barrett, 2003;
Roth & Dadds, 1999). In the current study, the manualised FRIENDS for Life program was
delivered by classroom teachers who were trained to administer program, during normal class
time within a standard school term. Outcomes were recorded post-treatment, and at 12
months follow-up.
The primary objective of this research was to evaluate the effectiveness of the
FRIENDS for Life program when delivered as a universal, school-based program in three
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schools from a socioeconomically disadvantaged region. Only two studies have attempted to
evaluate prevention of anxiety within disadvantaged schools exclusively. These studies,
neither of which employed the FRIENDS for Life protocol, yielded mixed results. The
ultimate goal was to provide support for the use of this intervention as a curriculum-based
program for anxiety in schools, in particular those within socioeconomically disadvantaged
regions.
FRIENDS for Life has been extensively validated as an effective intervention for
anxiety when delivered as a school-based program. In light of this, for the current study it
was predicted that anxiety symptoms would decrease from pre to post-intervention and
follow-up, based on child self-report measures. Similarly, as FRIENDS for Life has been
shown to effectively reduce depression in children, it was predicted that reductions in
depressive symptoms from pre to post-treatment and follow-up would be revealed, based on
child self-report measures.
The secondary focus of the current study was to examine the effects of the
intervention on both risk and protective factors and other indicators of psychosocial
functioning. It was predicted that use of positive coping skills, (assistance-seeking and
cognitive-behavioural problem-solving) would increase from pre to post-intervention and
follow-up. Accordingly, it was also predicted that the use of maladaptive coping skills,
(cognitive avoidance and behavioural avoidance), would decrease from pre to post-
intervention and follow-up. It was also hypothesised that self-esteem (social self-esteem and
school esteem) would increase from pre to post-intervention and follow-up. Lastly, it was
predicted that emotional problems, conduct problems, hyperactivity and inattention, and peer
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relationship problems would decrease from pre to post-intervention and follow-up, and that
pro-social behaviour would increase from pre to post-intervention and follow-up.
Finally, the current study sought to examine predictors of outcome with regards to
internalising symptoms post-intervention. Predictors included pre-intervention anxiety
symptoms, as well as pre-intervention positive coping skills (assistance-seeking and
cognitive-behavioural problem-solving), maladaptive coping skills (cognitive avoidance and
behavioural avoidance), self-esteem (social self-esteem and school esteem), emotional
problems, conduct problems, hyperactivity/inattention, peer relationship problems, and pro-
social behaviour. It was hypothesised that children with higher levels of self-reported anxiety
symptomatology at pre-intervention would demonstrate the greatest reductions in anxiety and
depressive symptomatology at post-intervention. With regards to coping skills, it was
predicted that children who reported using more maladaptive coping skills (cognitive
avoidance and behavioural avoidance) at pre-intervention would demonstrate greater
reductions in internalising symptoms at post-intervention. Similarly, it was predicted that
children with lower social self-esteem and school esteem at pre-intervention would
demonstrate greater reductions in internalising symptoms at post-intervention. Finally, it was
predicted that children with a higher level of emotional problems, conduct problems,
hyperactivity/inattention, and peer problems at pre-intervention, would show greater
reductions in internalising symptoms post-intervention.
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CHAPTER SIX
Method
Participants
The sample for the present study consisted of 963 children attending three public
primary schools located in Logan City, an urban local government region located South of
Brisbane, Australia. The sample consisted of 323 students in Grade 5, 340 students in Grade
6, and 300 students in Grade 7. The schools were matched for socio-economic level of
families attending the school. The sample consisted of 494 males and 469 females.
The three schools were selected based on their inclusion in a Community Renewal
program, an initiative of the Queensland Government Department of Housing. The
Community Renewal program involves collaboration between individual communities and
governments, focusing on addressing each community’s top priorities, such as community
safety, education, economic development, health and well-being, community infrastructure,
and accessibility of local services. Areas are selected based on a range of social and
economic indicators, and projects are jointly funded by the Queensland government, local
councils, businesses, and community organisations. The three schools included in this
research are located within the Marsden/Crestmead Community Renewal zone, a
geographical area within Logan City.
To officially quantify the level of socioeconomic disadvantage for the population
examined, data from the 2006 Census (ABS, 2008) was used to establish that the three
schools were located within a Statistical Local Area (SLA) associated with higher levels of
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socioeconomic disadvantage. To establish this, data for the relevant SLAs were investigated
using the Socio-Economic Indexes for Areas (SEIFA), a four-index analysis providing
relative rankings of SLAs according to level of social and economic wellbeing. The four
indices are: Index of relative socio-economic disadvantage; Index of relative socio-economic
advantage and disadvantage; Index of economic resources; and Index of Education and
Occupation. For the purpose of this research, the Index of relative socioeconomic
disadvantage was selected as the primary index of disadvantage, based on the Australian
Bureau of Statistics’ recommendation of its utility in comparing disadvantage to lack of
disadvantage, and as a broad measure of disadvantage in general (ABS, 2006). This index
summarises 17 different measures, including low income, low educational attainment, high
unemployment, and unskilled occupations (ABS, 2006). A full list of the 17 measures is
available in Figure 1.
 % Occupied private dwellings with no internet connection

 % Employed people classified as Labourers
 % People aged 15 years and over with no post-school qualifications
 % People with stated annual household equivalised income between
$13,000 and $20,799 (approx. 2nd and 3rd deciles)
 % Households renting from Government or Community organisation
 % People (in the labour force) unemployed
 % One parent families with dependent offspring only
 % Households paying rent less than $120 per week (excluding $0 per
week)
 % People aged under 70 who have a long-term health condition or
disability and need assistance with core activities
 % Occupied private dwellings with no car
 % People who identified themselves as being of Aboriginal and/or Torres
Straight Islander origin
 % Occupied private dwellings requiring one or more extra bedrooms
(based on Canadian National Occupancy Standard)
 % People aged 15 years and over who are separated or divorced
 % Employed people classified as Machinery Operators and Drivers
 % People aged 15 years and over who did not go to school
 % Employed people classified as Low Skill Community and Personal
Service Workers
 % People who do not speak English well
Figure 1. Variables used to calculate the index of relative socioeconomic disadvantage
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The SEIFA index of relative socioeconomic disadvantage yields several measures of
disadvantage for each SLA. The SEIFA rank is used to rank order all SLAs from lowest to
highest, based on relative socioeconomic disadvantage, where the lowest rank possible is 1.
The SEIFA decile divides areas into 10 equal groups; areas scoring in the lowest 10%
(indicating greatest socioeconomic disadvantage) are assigned decile number 1. The areas in
the highest 10% (indicating lowest socioeconomic disadvantage) are assigned decile number
10. Lastly, the SEIFA percentile places all regions on a percentile scale from 1 to 100, based
on relative socioeconomic disadvantage, where lower numbers indicate greatest
socioeconomic disadvantage. Ranks, deciles, and percentiles are available at both the
national and state level.
Two of the schools included in the current research were located within the SLA of
Marsden, whilst the third was located within the SLA of Waterford West. The SEIFA
measures of disadvantage (rank, decile, and percentile) for both these SLA regions, taken
from the 2006 Census data (ABS, 2008), are presented below in Table 2. These figures
demonstrate that both regions are areas of relative socioeconomic disadvantage, on both a
state and a national level.
Table 2
Measures of the SEIFA index of socioeconomic disadvantage by SLA
Marsden Waterford West

National SEIFA Rank 217 of 1394 SLAs 234 of 1394 SLAs
National SEIFA Decile 2 2
National SEIFA Percentile 16 17
Queensland SEIFA Rank 73 of 476 SLAs 82 of 476 SLAs
Queensland SEIFA Decile 2 2
Queensland SEIFA Percentile 16 18
Note. SEIFA = Socio-Economic Indexes for Areas; SLA = Statistical Local Area
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Measures
Strengths and difficulties questionnaire. The Strengths and Difficulties
Questionnaire (SDQ) (Goodman, 1997) is a 25 item self-report measure of psychological
adjustment for use with children aged 3 to 16 years. The items are divided between five
scales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship
problems, and pro-social behaviour. Participants are required to endorse either “not true” (0),
“somewhat true” (1), or “certainly true” (2) in response to each statement, with higher scores
indicative of greater problems for each subscale except for pro-social behaviour. The SDQ
has sound psychometric properties, including moderate to strong internal reliability for all
subscales, good test-retest reliability (Vostanis, 2006), concurrent validity, and the ability to
distinguish between community and clinical samples (Goodman, 2001; Goodman & Scott,
1999).
Self-esteem inventory. The Self-Esteem Inventory (SEI) (Coopersmith, 1967) is a
58-item self-report measure appropriate for use with children aged 8 to 15 years. The
measure consists of four subscales and a lie scale. The four subscales assess four separate
constructs of self-esteem: general self-esteem (e.g., “Things usually don’t bother me”); social
self-esteem (e.g., “I’m easy to like”); home esteem (e.g., “My parents understand me”); and
school esteem (e.g., “I’m doing the best work that I can”). Participants are required to
endorse either “like me” (1) or “unlike me” (0) in response to each statement, with higher
scores on each subscale indicative of higher self-esteem. The SEI has demonstrated sound
psychometric properties (Coopersmith, 1967, 1989), including good convergent validity and
an internal consistency of 0.86 (Robertson & Miller, 1986) (Kokenes, 1978). For the current
study, in the interest of condensing the size of the questionnaire battery, only items which
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were used to calculate social self-esteem (eight items) and school esteem (eight items)
subscales were included.
Children’s depression inventory. The Children’s Depression Inventory (CDI)
(Kovacs, 1981) is a 27-item self-report measure of depressive symptomatology in children
and adolescents. Items are designed to tap cognitive, behavioural, and affective symptoms of
depression. Participants are required to select from one of three given statements for each
item, which best represents their current position in terms of cognitions, behaviours, or
emotions. Depending on level of severity endorsed by the participant, items are scored as
either “0”, “1”, or “2”. A total score is derived by summing together the responses for each
item, with a higher score indicating a higher likelihood of depression. For the current study,
a cut-off score of 16 was used to indicate the presence of moderate to severe levels of
depressive symptoms, which is supported by the literature (Kovacs, 1992; Roberts, Kane,
Thomson, Bishop, & Hart, 2003). The CDI has demonstrated sound psychometric
properties, with high internal consistency and moderate test-restest reliability (Saylor, Finch,
Spirito, & Bennett, 1984), and good convergent validity in discriminating between clinically
depressed and non-depressed children in inpatient and non-referred groups (Kovacs, 1992;
Lobotvits & Handal, 1985; Saylor et al., 1984). For the current study, and consistent with
earlier research (Hannon, Rapee, & Hudson, 2000; Shochet et al., 2001), one item regarding
suicide was omitted so as not to cause concern to participants, parents, or teaching staff.
Research has shown that the removal of the suicide item does not significantly alter CDI
scores (Weiss et al., 1991).
Revised children’s manifest anxiety scale. The Revised Children’s Manifest
Anxiety Scale (Reynolds & Richmond, 1978) is a 37-item self-report measure of trait anxiety
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in children. A total of 28 items pertain to trait anxiety, with a further nine items assessing
social desirability. Items are presented as a series of statements, which participants are
required to endorse as being either true or not true of them, by indicating either “yes” (1) or
“no” (0) respectively. A total score is derived by summing together the responses for each
item, with a higher score indicating greater levels of anxiety. The RCMAS has sound
psychometric properties, with good convergent validity (Reynolds, 1980), high internal
consistency, and moderate test-retest reliability (Reynolds & Richmond, 1985).
Spence children’s anxiety scale. The Spence Children’s Anxiety Scale (SCAS)
(Spence, 1997) is a 44-item self-report measure of child anxiety suitable for use in
community samples. The SCAS consists of 38 items assess anxiety symptoms, including
obsessions and compulsions, separation anxiety, social phobia, panic, agoraphobia,
generalised anxiety, and physical injury concerns, which correspond to DSM-IV (American
Psychiatric Association, 1994) anxiety disorder subtypes. The scale is also composed of an
additional six positive filler items designed to reduce negative response bias, which were
omitted in the current study. Children respond through rating the frequency with which they
experience each symptom on a 4-point scale, from “never” (0), to “always” (3). Scores from
the 38 anxiety items are summed to produce a total anxiety score, with higher scores
indicating more severe difficulties. The SCAS was found to have high internal consistency,
satisfactory test-retest reliability, and adequate convergent and divergent validity (Spence,
1998; Spence, Barrett, & Turner, 2003). For the present study, a cut-off score of 42 was used
to identify children at high risk for anxiety. This cut-off was recommended by the author of
the scale (Spence, 1997), and has been used in previous research (Barrett, Farrell et al., 2006;
Barrett & Turner, 2001; Lock & Barrett, 2003).
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Coping scale for children and youth. The Coping Scale for Children and Youth
(CSCY) (Brodzinsky et al., 1992) is a 29-item self-report measure with four factors related to
coping: assistance seeking (e.g., sharing one’s feelings with another person),
cognitive/behavioural problem-solving (e.g., developing and following a plan to solve a
problem), cognitive avoidance (e.g., pretending the problem does not exist), and behavioural
avoidance (e.g., physically avoiding a problem situation). Children are requested to identify
a current or recent life stressor, and indicate the frequency with which they use each given
coping strategy in relation to this stressor, from “not at all” (1) to “very often” (4). Items
corresponding to each factor are calculated to yield a mean score for each four subscales.
The CSCY has moderate to high internal reliabilities for each of the four factors (ranging
from 0.70 to 0.80), with test-retest reliabilities within each of the factors ranging from 0.70 to
0.83 (Brodzinsky et al., 1992).
Procedure
Phase one: teacher training. Prior to the commencement of the program, all regular
classroom teachers of Grades 5, 6, and 7 at each of the three schools participated in a one-day
intensive training workshop, which provided education on childhood anxiety and depression,
theory behind the FRIENDS for Life program, and instruction in delivery of the FRIENDS for
Life program. The training workshops were delivered by postgraduate (doctorate and PhD)
psychology students, who were also accredited FRIENDS for Life trainers. The teacher
training sessions also included an introduction to the screening measures that would be used
as part of the research, and instruction on how to administer the questionnaires in a group
format. All training sessions were held in each of the three schools, over a period of one
week.
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Phase two: pre-intervention screening. Parents of all children in Grades 5, 6, and 7
of each of the three schools were sent an information sheet informing them of the research to
be conducted within their schools, and describing the data collection process and the
intervention itself. It was made clear that the intervention would be delivered during regular
class time, and at no cost to parents. No parents refused to allow their child to participate in
the program. This high acceptance rate may be due to a higher level of familiarity with the
FRIENDS program, given that past pupils of the schools had been involved in previous
research projects incorporating the FRIENDS program, which had included parent
information evenings and training sessions for teachers.
Students participated in the initial screening process, which was conducted within a
one-week period at each of the schools involved. Screening of each grade varied according
to time-tabling, and in one school a composite class of Grade 6 and 7 students was screened
simultaneously. Screening was completed in either classrooms or multi-purpose rooms
within each of the schools, with each student sitting at their own desk or in their own space,
to ensure the privacy of responses.
Prior to the commencement of the screening, participants were informed that all
responses were confidential, and that responses would only be viewed by the research staff.
Participants were also informed that the screening process was not a school test, and that
there were no right or wrong answers on the questionnaires. Screening within each school
was facilitated jointly by teaching staff and postgraduate psychology students, with a
minimum of one teacher and one postgraduate student at every screening session. Every
question on each of the six questionnaires was read aloud, in chronological order, by either
teaching or research staff, to ensure all participants comprehended the question regardless of
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differences in age and academic ability. Pauses were given after each question to allow
participants to record their responses, and participants were encouraged to raise their hand if
they did not understand a question, and a facilitator was able to assist them.
Phase three: intervention. The intervention phase commenced approximately one
week following the screening phase, with some variation in start dates both within and
between schools. The intervention was run on a class-by-class basis, with all program
sessions facilitated by the regular classroom teacher. Classroom teachers were instructed that
the program must be completed within one schooling term, with a recommended delivery
schedule of one session per week. Teachers were instructed that, provided all material within
each session was covered, and that each session was covered in chronological order, they did
not need to deliver each session as a whole block, but were able to split session content
between different time slots. The flexibility of the program delivery was necessary due to
individual differences in the curriculum between grades, timetabling differences between and
within schools, and the progress and composition of each individual class.
All children participating in the program received a copy of the FRIENDS for Life
workbook (Barrett, 2004), which they were able to keep at the completion of the program.
Classroom teachers were also supplied with a copy of the program manual (Barrett, 2004),
with detailed instruction on material to be covered in each session, and suggested activities
for each program component. Parents were encouraged to participate through attendance at
parent evening sessions held during the course of the intervention. These sessions, delivered
by a postgraduate psychology student and accredited FRIENDS for Life group facilitator,
were designed to provide education about childhood emotional development, anxiety and
depression in children, and instruction in various strategies that parents could use to assist
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their child in reducing their anxiety. These sessions were held in lieu of parental attendance
in the final stages of each session, which was unfeasible given that the sessions were
delivered during normal class time. Parent sessions were held in the evenings. Given the
poor attendance rates at four parent sessions in a previous universal school-based evaluation
of the FRIENDS for Life program (Barrett & Turner, 2001), only two parent sessions per
school were held.
Phase four: post-intervention screening. The post-intervention screening process
was conducted within one week at each of the schools, approximately one week following
completion of the last intervention session. As with the pre-intervention screening process,
post-intervention screening was completed either in classrooms or multi-purpose rooms in
each school, with each participant sitting individually to ensure the privacy of responses.
Participants were reminded again that all responses on the questionnaires were confidential,
and would only be viewed by the research staff. The screening was co-facilitated by teaching
and research staff. Again, all questions were read aloud to all participants.
Phase five: 12 months follow-up screening. At 12 months following completion of
the intervention, a postgraduate student returned to each of the three schools to assist
classroom teachers in completing the 12 months follow-up screening assessment of
participants. As the intervention had been completed with Grade 7 students of the previous
year, the 12 months follow-up screening process was only able to be completed with Grade 6
and Grade 7 students of the current year (Grade 5 and Grade 6 students of the intervention
year). The follow-up screening procedure was identical to that used in both the pre screening
and post screening phases.
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Intervention Protocol
FRIENDS for Life is a brief, group-based CBT for clinical anxiety in children
(Barrett, 2004). The program teaches children skills and techniques to manage anxiety and
cope with difficult situations. The primary components of the program include relaxation,
cognitive restructuring, attention training, graded exposure to anxiety-provoking situations,
and problem-solving, all of which are facilitated by peer and family support (Barrett &
Turner, 2004). The program originated as the Coping Koala program (Barrett, Dadds et al.,
1996), an Australian adaptation of the USA-originated Coping Cat program (Kendall, 1990).
The development of the Coping Koala program into a group intervention program resulted in
the birth of the FRIENDS program (Barrett, 1998; Shortt, Barrett, & Fox, 2001). The current
program is available in two developmentally appropriate versions: FRIENDS for Life (for
children aged 7 to 11 years) (Barrett, 2004) and FRIENDS for Youth (for children aged 12 to
16 years) (Barrett, 2005). Most recently, a downward extension of FRIENDS for Life,
entitled Fun FRIENDS (Barrett, 2007), has been developed for use with preschool-aged
children. The current research evaluated FRIENDS for Life, which is suitable for upper
primary school-aged children.
FRIENDS for Life is a manualised group-based intervention comprised of 12 sessions
of approximately 1.5 hours’ duration. In a clinic setting, the program is designed to be run as
10 weekly sessions and two booster sessions, held one and three months respectively after the
completion of the intervention. The recommended group size in a clinical setting is 6 to 10
participants. Whilst the intervention can be run individually, the group intervention process
helps to encourage and nurture participants to explore their emotions in a safe, supportive,
and collaborative environment. The FRIENDS program may be delivered by a single
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facilitator, but the addition of a co-facilitator is helpful to provide both individual and small-
group support to participants, as well as ensuring the sessions are run smoothly.
In a clinic setting, participants’ parents and siblings are encouraged to join the group
in the final 20 minutes of a session, allowing children to practice and reflect back what they
have learned in session by engaging in activities related to program skills with their parents.
This component of the sessions is useful in that it provides children with a sense of
accomplishment and reinforces learned material by allowing children to assume the role of
‘teacher’. It also demonstrates to parents the major themes and concepts covered in session,
so that they may better support their child in using FRIENDS strategies at home. This is also
facilitated by a number of ‘homework’ tasks, which encourage the practice of program skills
by all members of the family. In a school setting, this family component may be delivered as
a series of parent workshops, delivered at interval during the intervention.
The primary skills emphasised in the FRIENDS program are each denoted by a letter
in the FRIENDS anagram, each of which are discussed below. A breakdown of program
components covered by session is presented in Table 3.
Feelings. The feelings skill focuses on affective education, teaching children to
understand the range of emotions in themselves and in others, assisting in the development of
empathy. Children are taught to identify physiological signs (e.g. butterflies in the stomach,
muscle tension, racing heartbeat) and behavioural indicators (e.g. avoidance) of anxiety. It is
emphasised that these so-called “body clues” are normal, and provide the child with the
opportunity to explore what they are feeling. The family component of this skill encourages
family members to openly discuss and explore each other’s feelings, and practice focusing on
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the physiological responses to anxiety, thereby further normalising the experience of anxiety
in response to stressors.
Remember to relax. Have quiet time. This component teaches children relaxation
and self regulation skills in response to physiological arousal due to anxiety. Body clues are
identified as a ‘sign’ that the body needs to relax. Children receive instruction in several
relaxation techniques, including diaphragmatic breathing, progressive muscle relaxation, and
visual imagery, and are given the chance to practice in session and reflect on their experience
of relaxation. Families are encouraged to support this component through regular practice of
relaxation strategies at home. They are also asked to prioritise quiet time by way of
preventing stress and anxiety over the longer term. Parents may assist their children in
brainstorming relaxation and quiet time activities, such as listening to music, drawing
pictures, or going for a walk in the park.
I can do it! I can try my best! This third step comprises a key component of the
cognitive element of the FRIENDS for Life program, and an introduction to the concepts of
self-talk and thought challenging. Children are taught how to access their inner thoughts
(self-talk), and learn to discriminate between unhelpful “red” thoughts, and helpful “green”
thoughts. Red thoughts are identified as those which can make people feel sad and scared,
whilst green thoughts help people to feel happy and brave. Children are exposed to several
generic vignettes that may trigger red unhelpful thoughts, and are encouraged to challenge
these with more positive green thoughts. Children are then assisted to generate a situation
which is personally relevant, and practice challenging their red thoughts with positive green
thoughts. A secondary aspect of this component involves teaching children attention training
strategies, enabling them to identify and focus on the positive aspects of different scenarios.
112
Parents can nurture these skills at home by encouraging children to challenge negative
thinking, and to use green thoughts to improve mood and coping. Parents can assist both by
modelling this behaviour themselves, and through explicitly acknowledging and reinforcing
their child’s attempts at thought challenging.
Explore solutions and coping step plans. The fourth step of the FRIENDS for Life
program is comprised of two core learning components designed to help children cope in
challenging situations. The first is the coping step plan, a graded exposure hierarchy for a
feared or anxiety-provoking situation. Children are assisted in developing their own step plan
involving gradual exposure and response prevention, which will be followed for the
remainder of the program. The second component is instruction in problem solving,
presented to participants as the ‘Six Block Problem Solving Plan.’ This method includes the
following steps: (1) What is the problem - Define it!, (2) Brainstorm - list all possible
solutions, (3) List what might happen for each solution, (4) Select the best solution based on
the consequences, (5) Make a plan for putting this solution into practice and do it!, and finally
(6) Evaluate the outcome in terms of strengths and weaknesses, and if it did not work return
to step 2 and try again. The family element of this step involves teaching parents to create
their own coping step plans, and encouraging them to model the procedure at home. The
coping step plan may not necessarily be related to a feared situation, but may comprise a plan
for achieving a specific goal.
Now reward yourself! You’ve done your best! The rewards skill encourages
children to acknowledge their efforts and progress towards achieving their goals, and
recognise that trying one’s best, as well as succeeding, is deserving of a reward. This
component also introduces the notion of support networks, or ‘support teams’, which include
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role models within the home, school, and wider community. Children are encouraged to
think of who might be the best member of their support team to assist them with a range of
different challenges. Parents can support children at this stage by attending to and rewarding
proactive behaviours, thereby reinforcing the use of coping skills learned in the program.
This improves the likelihood that such behaviours will be maintained.
Don’t forget to practice & Smile! Stay calm for life! The final two program
components are delivered together. The former is designed to remind children that their
coping skills will improve with regular practice. The final component reminds participants
that they can remain calm because they have been equipped with the necessary coping
strategies to manage anxiety. Families can assist the maintenance of these strategies by
encouraging their continued use, and assisting children to plan for upcoming challenges.
Family discussions of how FRIENDS for Life skills may be used in these situations can assist
children to prepare and feel more comfortable in their coping ability.
Table 3
FRIENDS for Life components delivered per session
Session Number Session Content and Learning Objectives
1 Rapport building and introduction of group participants

Establishing group guidelines
Normalisation of anxiety and individual differences in anxiety
2 Affective education and identification of various emotions

Introducing the relationship between thoughts and feelings
3 F: Feelings.
Identifying physiological symptoms of worry
R: Remember to relax. Have quiet time
Relaxation activities
4 I: I can do it! I can try my best!

Identifying self-talk, introducing helpful green thoughts and
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unhelpful red thoughts
5 Attention training - looking for positive aspects in all situations

Challenging unhelpful red thoughts
E: Explore solutions and coping step plans
Coping step plans and setting goals
6 Problem-solving skills (6 stage problem-solving plan)

Coping Role models
Social support plans
7 N: Now reward yourself. You’ve done your best!
8 D: Don’t forget to practice

S: Smile. Stay calm for life!
Reflect on ways to cope in difficult situations
9 Generalising skills of FRIENDS to various difficult situations

Coaching others in how to use the FRIENDS coping skills
10 Skills for maintenance of the FRIENDS strategies

Preparing for minor set-backs that may occur
Booster 1 Review of FRIENDS strategies and preparing for future

challenges
Booster 2 Review of FRIENDS strategies and preparing for future

challenges
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CHAPTER SEVEN
Results
Preliminary Analyses
Preliminary analysis of the data revealed significant amounts of missing data at all
time points, which became larger at later time periods. Of the original sample of 963
participants, there was fully completed data for 486 participants at both pre and post (see
Table 4). Missing value analysis further confirmed that data were not missing randomly. T-
tests were used to compare the sub-sample of participants who completed the questionnaire
measures at both pre and post-intervention, with the sub-sample who completed measures at
pre-intervention, but not at post-intervention, to determine whether there were any significant
differences in pre-intervention levels of internalising symptoms and other outcome measures.
There were no significant differences on any of the outcome measures at pre-intervention
between these two groups.
Due to the large amount of missing data, it was decided to analyse only complete data
points using Linear Mixed Effects models. This was used for the analysis of the overall
effect of treatment across the three time points, with participant identity as a random factor,
time as repeated measures, and an unstructured covariance metric. Linear mixed effects
models include all observations which are valid at each time point (Cnaan, Laird, Slassor,
1998). For subsequent analyses, ANOVAs, t-tests and regressions were performed on
difference scores formed from the difference between pre-intervention and post-intervention
scores on each measure, and therefore include only participants who completed both
assessments. Although there may still be issues of generalisability of findings derived from
116
these analyses, the analysis of complete data is less problematic for multivariate analyses than
is imputation of data when data are non-randomly and extensively missing, as these analyses
make less assumptions about the nature of the missing data and therefore produce less biased
estimates (Kalton & Kasprzyk, 1982).
All measures showed some degree of skew. Analyses were performed with both
untransformed and transformed data, using each of the square-root, logarithm, and power
transforms. The optimal transform was selected using the Box-Cox procedure, which
identifies the power transform which most closely resembles normality for any continuously
scaled variable (Box & Cox, 1964) for each variable. Where substantive differences were
observed, these are presented in the analyses. No significant outliers were observed after
transformation. Due to the large number of analyses calculated, only significant F-ratios will
be reported.
Table 4
Sample size for all measures analysed, across time points
Measure Pre Post Follow up

n n n
SCAS
Total 833 490 200
Panic Disorder 828 489 200
Separation Anxiety 832 490 200
Physical Injury 833 488 200
Social Phobia 832 490 200
OCD 829 487 200
GAD 833 488 200
RCMAS 610 488 199
CDI 830 512 195
SDQ
Emotional Problems 605 516 199
Conduct Problems 605 516 199
Hyperactivity/Inattention 605 516 199
Pro-social Behaviour 605 516 199
Peer Problems 605 516 199
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SEI
Social Self-esteem 626 508 196
School Esteem 626 509 196
CSCY
Assistance Seeking 523 391 141
Problem Solving 523 391 141
Cognitive Avoidance 523 391 141
Behavioural Avoidance 523 392 141
Note. SCAS = Spence Children’s Anxiety Scale; RCMAS = Revised Children’s Manifest
Anxiety Scale; CDI = Children’s Depression Inventory; SDQ = Strengths and Difficulties
Questionnaire; SEI = Self Esteem Inventory; CSCY = Coping Scale for Children and Youth.
Differences in Baseline Measures (School, Gender, and Grade).
Preliminary examination of the data indicated that the gender and grade distributions
were not significantly different between the three schools (see Table 5). A series of one-way
ANOVAs comparing the three schools in terms of baseline anxiety and depression (see Table
6) showed that one of the three schools (Waterford West) had significantly lower depression
scores than the other two schools, F(2,573) = 4.56, p = .011. Another of the three schools
(Crestmead) had significantly lower scores on the SCAS separation anxiety subscale than did
the other two schools, F(2,573) = 4.18, p = .016.
Table 5
Sample sizes for each school, by grade and gender
School Grade 5 Grade 6 Grade 7

Male Female Male Female Male Female
Burrows 55 57 48 55 40 34
Waterford West 43 46 46 56 43 43
Crestmead 67 55 80 55 72 68
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Table 6
Mean and standard deviation for all clinical outcome measures at baseline
School
Burrowes Waterford West Crestmead
x̄ SD x̄ SD x̄ SD
SCAS
Total 27.87 20.46 27.40 21.95 27.26 19.42
Panic Disorder 3.83 5.09 4.14 5.17 3.78 4.51
Separation Anxiety 4.73 3.80 4.79 4.37 4.35 3.60
Fear of Physical Injury 3.35 3.10 3.36 3.24 3.20 3.15
Social Phobia 5.35 4.21 5.25 4.28 5.24 4.03
OCD 5.10 4.12 4.93 4.18 5.27 4.02
GAD 5.50 4.09 5.16 4.07 5.42 4.11
RCMAS 15.32 7.64 14.45 6.79 14.45 7.25
CDI 11.67 9.59 10.20 8.42 11.73 8.61
Note. SCAS = Spence Children’s Anxiety Scale; RCMAS = Revised Children’s Manifest
Anxiety Scale; CDI = Children’s Depression Inventory.
Two-way ANOVAs of each clinical measure indicated that overall, girls had
significantly higher anxiety scores than boys, as measured on the SCAS, F(1,827) = 35.93, p
< .001. A similar effect of gender was noted with regards to anxiety scores on the RCMAS,
whereby girls reported significantly higher anxiety than boys, F(1,604) = 11.91, p < .001.
With regards to differences in anxiety between the three grades, children in Grade 7 were
found to have lower anxiety scores on the SCAS than children in Grade 5, F(2,827) = 3.08, p
= 0.046. Children in Grade 6 did not significantly differ from the other two groups in terms
of overall anxiety scores on the SCAS. When investigating self-reported anxiety symptoms
on the RCMAS, children in Grade 7 exhibited less anxiety than children in either Grade 5 or
Grade 6, F(2,604) = 6.05, p = 0.002. Children in Grade 5 and Grade 6 did not differ
significantly in terms of self-reported anxiety on the RCMAS.
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Treatment Effects.
Anxiety. Table 7 shows the changes on all outcome measures over time. On the
SCAS total score, a significant main effect for time was found, F(2,120.08) = 33.05, p<.001,
indicating that anxiety scores did change over time. Anxiety scores decreased significantly
from pre to post intervention, though there was no significant difference between post-
intervention and follow-up scores. Similarly, for the RCMAS a significant main effect for
time was found, F(2,102.54) = 20.7, p<.001. Self-rated anxiety on this measure significantly
decreased from pre to post-intervention, though there was no significant difference between
post-intervention and follow-up RCMAS scores.
Significant main effects for time were also noted on all SCAS subscales. Contrasts
examining the main effect of time on the subscale for GAD, F(2,168) = 44.38, p<.001,
demonstrated that scores decreased significantly from pre to post-intervention, with
significant decreases also noted between post and follow-up scores. Contrasts examining the
main effect of time on the subscales for PD, F(2,201.29) = 14.33, p<.001, SAD, F(2,157.07)
= 34.33, p<.001, and OCD, F(2,168) = 44.38, p<.001, revealed that scores significantly
decreased from pre to post-intervention, with no significant differences noted between post-
intervention and follow-up scores. By comparison, contrasts examining the main effect of
time on the subscales for fear of physical injury F(2,101.29) = 4.87, p = 0.01, and SP,
F(2,133.68) = 16.64, p<.001, revealed that whilst significant decreases from pre to post were
evident, there were significant increases in scores on both scales from post to follow-up.
Depression. On the CDI, a significant main effect for time was found, F(2,112.7) =
14.77, p<.001, whereby self-rated depression significantly decreased from pre to post-
120
intervention. No significant difference was noted in depression scores from post-intervention
to follow-up.
Self-esteem, coping skills, and psychosocial difficulties. A significant main effect
of time was noted for the SDQ emotional problems subscale, F(2,147.29) = 14.68, p<.001,
whereby scores on this scale decreased from pre to post, with no significant difference
between post and follow-up scores. Significant main effects of time were also found for both
the CSCY cognitive avoidance subscale, F(2,277.95) = 11.52, p<.001, and the CSCY
behavioural avoidance subscale, F(2,243.32) = 11.19, p<.001, with contrasts indicating
significantly lower scores from pre to post-intervention, with further decreases noted between
post-intervention and follow-up scores. Significant main effects of time were also found for
the SDQ peer problems subscale F(2,195.19) = 7.1, p = 0.001, SEI social self-esteem
subscale, F(2,108.17) = 5.49, p = 0.005, CSCY problem solving subscale, F(2,228.82) =
11.56, p<.001, and for the transformed SDQ conduct problems subscale, F(2,179.77) = 5.61,
p = 0.004. Contrasts performed on each of these main effects revealed no significant
differences in scores for the above scales from pre to post-intervention, but demonstrated
significantly higher follow-up scores for the SEI social self-esteem scale, relative to those
both pre and post intervention, and significantly lower follow-up scores for the CSCY
problem solving subscale, SDQ peer problems subscale, and the transformed SDQ conduct
problems subscale, relative to those both pre and post intervention.
Change in risk status. Changes in risk status over time are displayed below in
Figure 2. Overall, 21.9% of children exhibited levels of anxiety at or above the clinical cut-
off on the total SCAS score at baseline, which reduced to 14.7% at post-test and 12% at
follow-up. On the CDI, 30.4% of children scored above the clinical cut-off for depression at
baseline, and this rate dropped to 23.4% at post-test, and 21% at follow-up.
121
35
30
Percentage of participants at risk
25
20
Pre
Post
15 Follow-up
10
0
SCAS CDI
Questionnaire Measure
Figure 2. Change in risk status over time.
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Table 7
Mean (and standard deviation) for all measures at pre-intervention, post-intervention and follow-up
Pre-test Post-test Follow-up Change over time

SCAS
Total 27.48 (20.44) 22.23 (17.06) 22.17 (18.23) F(2,120.08) = 33.05, p<.001***
Panic Disorder 3.89 (4.87) 3.01 (4.13) 3.07 (4.47) F(2,201.29) = 14.33, p<.001***
Separation Anxiety 4.59 (3.89) 3.59 (3.35) 3.37 (3.33) F(2,157.07) = 34.33, p<.001***
Fear of Physical Injury 3.29 (3.16) 2.96 (2.85) 3.06 (3.06) F(2,101.29) = 4.87, p = 0.01***
Social Phobia 5.28 (4.15) 4.42 (3.65) 4.71 (3.55) F(2,133.68) = 16.64, p<.001***
OCD 5.13 (4.09) 3.77 (3.45) 3.64 (3.52) F(2,168) = 44.38, p<.001***
GAD 5.37 (4.09) 4.55 (3.32) 4.34 (3.78) F(2,133.08) = 20.45, p<.001***
RCMAS 14.76 (7.25) 13.01 (6.72) 13.01 (6.58) F(2,102.54) = 20.7, p<.001***
CDI 11.26 (8.86) 9.4 (8.21) 8.72 (8.21) F(2,112.7) = 14.77, p<.001***
SDQ
Emotional Problems 3.69 (2.41) 3.2 (2.22) 3.06 (2.26) F(2,147.29) = 14.68, p<.001***
Conduct Problems 2.99 (2.1) 2.77 (1.97) 2.41 (1.92) F(2,179.77) = 5.61, p = 0.004***
Hyperactivity/Inattention 4.25 (2.31) 4.01 (2.27) 4.08 (2.5) F(2,99.11) = 1.73, p = 0.183
Peer Problems 2.5 (1.91) 2.43 (1.82) 2.03 (1.74) F(2,195.19) = 7.1, p = 0.001***
Pro-social Behaviour 7.26 (1.96) 7.28 (1.9) 7.56 (1.95) F(2,211.75) = 1.22, p = 0.298
SEI
Social Self-esteem 5.8 (1.96) 5.93 (1.94) 6.16 (1.73) F(2,108.17) = 5.49, p = 0.005***
School Esteem 5.54 (1.73) 5.57 (1.79) 5.7 (1.63) F(2,171.95) = 0.35, p = 0.705
CSCY
Assistance Seeking 8.83 (2.77) 8.75 (2.67) 8.32 (2.84) F(2,265.63) = 1.75, p = 0.176
Problem Solving 16.68 (5.69) 16.21 (5.54) 14.55 (5.46) F(2,228.82) = 11.56, p<.001***
Cognitive Avoidance 23.42 (7.47) 22.07 (7.13) 20.38 (7.46) F(2,277.95) = 11.52, p<.001***
Behavioural Avoidance 11.1 (3.87) 10.6 (3.53) 9.63 (3.69) F(2,243.32) = 11.19, p<.001***
Note. SCAS = Spence Children’s Anxiety Scale; RCMAS = Revised Children’s Manifest Anxiety Scale; CDI = Children’s Depression
Inventory; SDQ = Strengths and Difficulties Questionnaire; SEI = Self Esteem Inventory; CSCY = Coping Scale for Children and Youth.
123
Predictors of improvement
Gender and grade. A series of two-way ANOVAs were conducted
examining whether improvement (difference between pre-intervention and post-
intervention scores) was related to the grade or gender of participants. For the SCAS
total score, there was an effect of gender, such that girls demonstrated a higher
improvement score than boys, F(1, 412) = 34.77, p < .001. However, it was found
that boys’ difference scores for the SCAS social phobia subscale were significantly
greater than girls’ scores, F(1,418) = 5.14, p = .024.
Two main effects were revealed with regards to difference scores on several
secondary outcome measures. There was a significant main effect of gender for the
SDQ Peer Problems subscale, such that boys’ scores on this measure decreased more
than girls’ scores, F(1,308) = 5.34, p = .022. With regards to self-esteem, there was a
significant main effect of gender for the SEI subscale for social self-esteem, such that
boys’ scores increased more than girls’ scores, F(1,326) = 9.96, p = .002. There was
also a significant two-way interaction of grade and gender for the SEI social self-
esteem subscale, such that scores increased more for boys than for girls in Grades 5
and 6, with no significant difference between boys and girls in Grade 7, F(2,326) =
3.62, p = .028.
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Table 8
Means and standard deviations for difference between pre-intervention and post-intervention scores
Male Female
Grade Grade
5 6 7 5 6 7
x̄ SD x̄ SD x̄ SD x̄ SD x̄ SD x̄ SD
SCAS
Total -7.16 19.91 -6.52 20.58 -5.91 12.61 -5.66 17.38 -4.85 17.07 -3.43 14.49
Panic Disorder -1.20 5.36 -1.53 5.91 -.48 3.90 -1.00 4.00 -1.14 5.21 -.32 3.67
Separation Anxiety -1.22 3.29 -1.30 3.82 -.87 2.20 -1.36 4.14 -1.00 3.44 -.60 3.19
Fear of Physical injury -.45 2.84 -.05 2.74 -.23 1.93 -.79 2.80 -.32 2.80 -.14 2.60
Social Phobia -1.66 4.11 -.87 3.71 -1.61 2.81 -.90 3.67 -.32 3.43 -.53 3.76
OCD -1.50 4.66 -1.87 4.65 -1.41 3.30 -.94 4.07 -1.32 3.89 -1.31 3.76
GAD -1.16 4.02 -.95 4.10 -1.32 3.15 -.67 3.50 -.75 4.06 -.52 3.47
RCMAS -3.57 6.19 -1.10 6.81 -.92 5.44 -1.59 6.53 -1.33 6.53 -1.33 5.99
CDI -.72 8.32 -1.71 9.82 -2.74 6.76 -.87 8.58 -.18 7.67 -2.68 6.19
SDQ
Emotional Problems -.76 2.10 -.61 1.99 -.16 2.36 -.42 1.99 -.65 2.50 -.38 2.38
Conduct Problems .05 2.36 -.50 1.96 .28 2.23 -.14 1.85 -.41 1.96 -.13 1.77
Hyperactivity/Inattention .10 1.99 .22 1.85 -.36 2.15 -.07 2.16 -.11 2.37 -.28 1.91
Peer Problems -.02 1.63 -.67 2.17 -.34 1.70 .28 1.86 .07 1.81 .01 1.52
Pro-social Behaviour .40 2.10 .11 2.17 .43 2.37 -.28 1.89 .31 2.03 -.25 1.93
SEI
Social Self Esteem .38 1.31 .16 1.71 -.16 1.84 .05 2.07 -.06 1.56 .16 1.49
School Esteem .81 1.77 .53 1.65 .03 1.83 -.41 1.63 -.14 1.91 .09 1.53
CSCY
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Assistance Seeking 1.00 3.99 -1.10 3.66 .74 3.36 -.34 3.25 .25 3.40 -.30 3.66
Problem Solving -1.35 8.83 -3.23 5.44 .05 7.90 -2.28 5.76 -.86 5.25 -.70 6.55
Cognitive Avoidance -3.45 11.72 -3.27 10.06 -2.17 9.19 -4.48 9.20 -2.41 9.11 -.15 9.20
Behavioural Avoidance -.60 5.20 -2.20 5.24 -.55 4.78 -1.31 5.04 -1.25 4.01 .06 3.68
Note. SCAS = Spence Children’s Anxiety Scale; RCMAS = Revised Children’s Manifest Anxiety Scale; CDI = Children’s Depression
Inventory; SDQ = Strengths and Difficulties Questionnaire; SEI = Self Esteem Inventory; CSCY = Coping Scale for Children and Youth.
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Baseline anxiety. Anxiety level at baseline was associated with the
effectiveness of the intervention, in terms of the difference between anxiety levels at
pre- and post-treatment. Improvement in SCAS-total score was correlated -.62 (p <
.001) with SCAS-total score at baseline, such that those with higher initial levels of
anxiety demonstrated a significantly greater decrease in anxiety symptoms post-
intervention.
Participants were stratified into low-risk and at-risk groups, based on their pre-
intervention total score on the SCAS. Participants were assigned to the low-risk
group based on scores below the clinical cut-off score of 42, whilst participants
scoring at or above this cut-off were allocated to the at-risk group. Improvement
scores were examined on the SCAS total score, RCMAS and CDI, as a function of
risk status, age, and grade, to establish whether there were differential patterns of
improvement. Of the 833 children who completed the SCAS at baseline, 183 (21.9%)
were allocated to the at-risk group based on their pre-intervention SCAS score.
Children in the at-risk group demonstrated significantly greater improvement than
children in the low-risk group on all primary outcome measures, F(1, 410) = 8.1, p =
.005 for CDI, F(1,305) = 12.28, p < .001 for RCMAS, and F(1,412) = 199.66, p <
.001 for SCAS-total. For the SCAS total score, there was a significant two-way
interaction of gender and clinical status F(1,412) = 23.15, p < .001; children in the at-
risk group experienced significantly greater reduction in self-reported anxiety than
those in the low-risk group, but this effect was stronger for boys than for girls.
Self-esteem, coping style, strengths and difficulties. Bivariate correlations
were examined to ascertain whether improvement on the clinical measures differed
according to psychosocial characteristics of participants at pre-intervention (see Table
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9). Children with higher scores on the SDQ emotional problems subscale at pre-
intervention had significantly lower post-intervention scores on the SCAS, RCMAS,
and CDI, whilst children with higher scores for pro-social behaviour pre-intervention
had greater reductions on the CDI only. Children with lower scores on both SEI
subscales for social self-esteem and school esteem pre-intervention were more likely
to have lower scores on the CDI at post-intervention, whilst children with higher
scores on the CSCY behavioural avoidance subscale at pre-intervention had
significantly lower scores on both the SCAS total scale and the CDI at post-
intervention.
Table 9
Pearson bivariate correlations between psychosocial predictors and difference scores
in outcome (difference from pre to post on each clinical measure)
SCAS total RCMAS CDI

Correlation, p, N Correlation, p, N Correlation, p, N
SDQ
Emotional Problems -0.24 (0, 296) * -0.24 (0, 294) * -0.21 (0, 302) *
Conduct Problems -0.11 (0.05, 296) 0 (0.985, 294) -0.12 (0.037, 302)
Hyperactivity/Inattent -0.1 (0.09, 296) -0.05 (0.368, 294) -0.11 (0.061, 302)
Pro-social Behaviour -0.1 (0.094, 296) -0.07 (0.266, 294) -0.23 (0, 302) *
Peer Problems 0 (0.993, 296) -0.01 (0.842, 294) 0.13 (0.022, 302)
SEI
Social Self-esteem 0.08 (0.149, 318) 0.16 (0.005, 316) 0.29 (0, 317) *
School Esteem 0.07 (0.237, 318) 0.05 (0.372, 316) 0.24 (0, 317) *
CSCY
Assistance Seeking -0.07 (0.254, 276) -0.1 (0.105, 276) -0.01 (0.92, 280)
Problem Solving -0.19 (0.002, 276) -0.18 (0.002, 276) -0.01 (0.899, 280)
Cognitive Avoidance -0.18 (0.003, 276) -0.12 (0.054, 276) -0.11 (0.057, 280)
Behaviour Avoidance -0.27 (0, 276) * -0.19 (0.002, 276) -0.23 (0, 280) *
***significant at < .001 (bonferonni correction)
Note. SCAS = Spence Children’s Anxiety Scale; RCMAS = Revised Children’s
Manifest Anxiety Scale; CDI = Children’s Depression Inventory; SDQ = Strengths
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and Difficulties Questionnaire; SEI = Self Esteem Inventory; CSCY = Coping Scale
for Children and Youth.
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CHAPTER EIGHT
Discussion
The purpose of this study was to investigate the effectiveness of a universal
school-based intervention program for childhood anxiety (FRIENDS for Life) for
upper primary-school aged children (aged 9 to 13 years) within a socioeconomically
disadvantaged community. The primary objective was to examine changes in anxiety
and depressive symptomatology from pre to post-intervention, and at 12 months
follow-up. Consistent with predictions, participants reported significantly less anxiety
symptoms, as measured on both the SCAS and RCMAS, following the completion of
the intervention. There was no significant difference in total anxiety symptom scores
between post-intervention and 12-month follow-up on either anxiety measure,
indicating that the positive treatment gains were maintained over time. Furthermore,
as predicted, participants also reported significantly less depressive symptoms, as
measured by the CDI, following the intervention. As with anxiety symptom scores,
the improvements in depressive symptomatology were robust over time. With regards
to anxiety risk status, 75% of participants were no longer in the “at-risk” range for
anxiety at post-intervention, with this percentage increasing to 88% at 12-months
follow-up.
The findings noted above are consistent with earlier research which has
demonstrated immediate reductions in child-reported anxiety symptoms, following
implementation of a universal CBT program (Barrett & Turner, 2001; Lock & Barrett,
2003; Lowry-Webster, Barrett, & Dadds, 2001). The finding that the reductions in
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anxiety symptoms were maintained at 12 months follow-up is also consistent with
previous research investigating the longitudinal effects of universal prevention for
anxiety (Barrett, Lock et al., 2005; Barrett, Farrell, Ollendick, & Dadds, 2006; Lock
& Barrett, 2003; Lowry-Webster, Barrett, & Lock, 2003; Stallard et al., 2008). From
the perspective of intervention within socioeconomically disadvantaged populations,
the findings of this research are consistent with those of Misfud and Rapee (2005),
who also found significant decreases in anxiety symptomatology from pre to post-
intervention in children who completed an indicated intervention for anxiety. By
comparison, the significant reduction in anxiety symptoms found in the current study
contrast the findings of Roberts, et al. (2010), who failed to demonstrate significant
differences in child-reported internalising symptoms from pre to post-intervention.
This discrepancy may be due to the different intervention protocol used by the current
study, as compared to that employed by Roberts et al. (2010).
Whilst the primary outcome measure of the current study was anxiety
symptomatology, the current research also revealed significant reductions in child-
reported depression symptoms over time. This finding is consistent with earlier
research which has also found reductions in depression following implementation of
the FRIENDS program (Barrett, et al., 2006; Lock & Barrett, 2003; Lowry-Webster,
et al., 2003). Taken together, this evidence suggests that FRIENDS for Life may be
effective in reducing internalising symptomatology in general, rather than anxiety
specifically. This theory is in keeping with research demonstrating the high rate of
comorbidity between anxiety and depression (Angold, Costello, & Erkanli, 1999;
Costello, Egger, & Angold, 2005), suggesting a possible common mechanism
underlying both symptom clusters which is responsive to CBT treatment. With
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regards to the current study, it is notable that reductions in depressive
symptomatology were evident immediately at post-intervention. This is in contrast
with earlier research, where protective effects for depression emerged only at 12
months post-intervention (Lock & Barrett, 2003), or not at all (Barrett, Lock et al.,
2005; Roberts, et al., 2010). A possible explanation for the immediate response seen
in the current study may be related to the population sample, given that children from
disadvantaged populations are at greater risk for internalising disorders and
psychopathology (Costello, et al., 1996; Kessler, et al., 1994; Miech, Caspi, Moffitt,
Entner Wright, & Silva, 1999; Xue, Leventhal, Brooks-Gunn, & Earls, 2005).
As with several earlier studies of universal prevention in schools (Barrett,
Lock et al., 2005; Lock & Barrett, 2003; Stallard, et al., 2008), the current study was
affected by considerable amounts of missing data. In outcome studies of this nature,
there is always a question of whether the interpretability of significant results may be
compromised by differential rates of attrition according to symptom severity at pre-
intervention. In drawing conclusions from available data, it is important to
distinguish whether or not participants are more likely to drop out due to higher levels
of internalising symptoms pre-intervention. Such drop-out would invariably bias
results, given that post-intervention outcomes would be based primarily on the scores
of individuals with less severe difficulties to begin with. In the current study, no
significant differences in pre-intervention anxiety and depressive symptoms were
found between those participants who completed questionnaire measures at pre and
post-intervention, and those who completed measures at pre but not at post. This is an
important finding in the context of our results; it appears that significant reductions in
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internalising symptoms post-intervention are not purely an artefact of missing data,
and as such the results presented above can be interpreted with greater confidence.
The present study also examined whether risk and protective factors for
childhood anxiety (principally, the use of maladaptive and positive coping strategies,
and self-esteem) would be modified following the completion of the intervention.
With regard to effects on the use of coping skills as measured by the CSCY
(assistance seeking, cognitive behavioural problem solving, cognitive avoidance, and
behavioural avoidance), the hypotheses were partially supported. Self-reported use of
cognitive avoidance and behavioural avoidance decreased significantly from pre to
post-intervention, and again from post-intervention to follow-up. This finding
suggests that participants were more likely to address and confront challenging and
anxiety-provoking situations following the intervention. Additionally, the significant
decrease from post to follow-up suggests that participants became more confident in
approaching challenges over time. This reduction of avoidance may facilitate the
decrease of anxiety symptoms over the long-term, given that reduced avoidance
allows for exposure to feared situations, giving children the opportunity to habituate
to such situations. The findings outlined above are similar to those reported in the
universal prevention study conducted by Lock and Barrett (2003), who found
significant decreases in both cognitive and behavioural avoidance as coping skills.
The findings of the current study are also consistent with research attesting to the role
of avoidant coping strategies in perpetuating anxiety in children Barrett, Rapee,
Dadds, & Ryan, 1996; Herman-Stahl & Petersen, 1996; Lengua, Sandler, West,
Wolchick, & Curran, 1999; Prior, Smart, Sanson, & Oberklaid, 2000).
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By comparison, and contrary to prediction, use of cognitive behavioural
problem solving as a coping strategy significantly decreased 12 months post-
intervention, whilst there was no significant change in the use of assistance-seeking as
a coping strategy across time. These results indicate that participants were less likely
or no more likely to use these positive coping skills, following the intervention.
These results may be partly reconciled with those reported by Lock and Barrett
(2003), who investigated changes in coping strategies (assessed using the CSCY) for
children in Grade 6 (late primary school) and Grade 9 (early high school). In this
study, whilst it was found that females and children from the Grade 9 group reported
increased cognitive behavioural problem solving and assistance-seeking post-
intervention, improvements had disappeared at 12 months follow-up. The study’s
authors concluded that whilst younger children were less likely to avoid anxiety-
provoking situations post-intervention, they were also less likely to use positive
coping strategies post-intervention than older children. This may be reflected again
by results of the current study, given that the sample was comprised of late primary
school-aged children. In reconciling these findings with the FRIENDS program
content, the significant decrease in the use of cognitive and behavioural avoidance as
coping strategies suggest that children of late primary school age respond well to the
FRIENDS component incorporating graded exposure. In this component, children are
taught to come up with step plans to actively address anxiety provoking situations.
By comparison, the failure to find hypothesised improvements in positive coping
strategies (assistance seeking and cognitive behavioural problem solving) suggests
that greater efforts are needed to improve the way that positive coping strategies are
taught to children in the FRIENDS program.
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Predicted improvements in self-reported self-esteem were also found by the
current study; specifically, self ratings on the social self-esteem subscale of the SEI
were significantly higher at 12 months follow-up, relative to scores at pre and post-
intervention. This finding suggests that participants were more likely to view
themselves positively, and as being more popular and likeable within their peer group,
one year after the intervention. By comparison, the expected change in self-reported
school esteem (on the school esteem subscale of the SEI) was not found, suggesting
that children’s self-esteem with regards to their school efforts and achievement did
not vary in response to the intervention. Though the predictions were only partially
supported, the findings above have positive implications for children with anxiety.
Given that low self-esteem has been associated with anxiety in children (Ialongo,
Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1996; McLoone, Hudson, &
Rapee, 2006; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005; Strauss, Frame,
& Forehand, 1987), improvements in self-esteem may act as a protective factor
against anxiety difficulties in the future.
The above findings regarding self-esteem may be interpreted in the context of
the content of the FRIENDS program. In reconciling these findings with the program
content, it may be argued that the intervention is geared more towards the promotion
of general and social self-esteem, rather than self-esteem related to a specific aspect of
functioning such as that measured by the school esteem subscale of the SEI. This can
be seen through activities encouraging team work, social support, cognitive
challenging, and use of positive self-talk. Whilst each of these elements may
certainly be applied to functioning within the school domain, aspects which relate
specifically to school esteem, such as pride in one’s work, attitude towards school and
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learning, and relationships with school teachers, are not explicitly dealt with by the
program. It would be interesting to investigate whether the inclusion of a ‘school’
component in the standard protocol would yield any significant improvements in
school esteem in future research.
The improvements in self-esteem outlined above are similar to those reported
by Stallard et al. (2008), who found significant improvements in total self-esteem
from pre-intervention to 3 months post-intervention and 12-months follow-up. The
results are also similar to those of Barrett, Sonderegger, and Xenos (2003), who noted
significant improvements in self-esteem for participants in the intervention condition,
both from pre to post-intervention, and from post-intervention to 6 months follow-up.
In comparison to the previously mentioned research however, improvements in self-
esteem did not become apparent in the current study until 12 months post-
intervention. The delayed improvement in self-esteem scores may be due to
participants requiring enough time to build up confidence to engage in a range of
different situations and activities that may have previously been avoided, which
would serve to increase self-esteem over the long-term.
With regards to other measures of psychosocial functioning, significant
improvements were noted in several areas. As predicted, self-reported emotional
problems decreased significantly from pre to post-intervention, with these gains
maintained at 12 months follow-up. These findings are consistent with the significant
decreases in anxiety and depressive symptomatology reported above, providing
further evidence for the effectiveness of the intervention. By comparison, self-
reported peer problems remained stable from pre to post-intervention, but improved
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significantly at 12-months follow-up. This finding indicates that children reported
experiencing significantly fewer problems within their peer group 12 months
following the intervention. This compliments the earlier reported finding of
significant increases in social self-esteem, which suggested children felt they were
more liked by their peers. Similar to changes in self-esteem, significant reductions in
self-reported peer problems did not emerge until 12 months post-intervention,
suggesting children may require more time to practice their new skills before reaping
social benefits.
Predicted improvements in self-reported conduct problems were also noted.
Whilst these problems remained stable from pre to post-intervention, significant
decreases were evident at follow-up, indicating that children reported exhibiting fewer
disruptive behavioural problems 12 months following the intervention. This
reduction may also be in part related to decreases in peer problems, improvements in
self-esteem, and reduction in internalising difficulties in general, such that children
were less likely to act out behaviourally. By comparison, predicted improvements in
self-reported pro-social behaviour were not observed, which is interesting given the
improvements noted in the areas of self-esteem and peer problems. Lastly, there was
no significant reduction in self-reported hyperactivity and inattention, suggesting that
these issues may be better addressed by other interventions tailored more specifically
to problem behaviours.
The secondary focus of this research was to investigate predictors of
improvement (difference between pre-intervention and post-intervention scores) on
the primary outcome measures (anxiety and depressive symptomatology), and
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secondary outcome measures (coping skills, self-esteem, and psychosocial factors).
In terms of demographic predictors, girls demonstrated significantly greater
improvement in anxiety symptoms post-intervention, a finding consistent with earlier
research (Barrett, et al., 2006; Lock & Barrett, 2003). However, given that some
researchers have failed to find significant gender differences in terms of symptom
improvement (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Lowry-Webster, et
al., 2003; Roberts, et al., 2010; Shortt, Barrett, & Fox, 2001), whilst others have
reported greater improvement in boys (Dadds, et al., 1999), further research may be
required to conclusively identify gender differences in response to treatment. It was
also found that males were significantly more likely than females to demonstrate
decreases in SOP symptoms post-intervention, suggesting that boys may derive
greater benefits than girls from the FRIENDS program in terms of developing social
confidence. This finding has some important implications in terms of social
development in boys, who typically lag behind girls in terms of establishing
meaningful social relationships from a young age. It appears the FRIENDS program
may impart the necessary skills and strategies for boys to approach social situations
with greater confidence.
The current research failed to identify any between-grade differences in terms
of improvement in internalising difficulties. Several earlier studies investigating
developmental differences in universal anxiety prevention established that children
from younger grades tend to respond more positively to treatment (Barrett, Lock et
al., 2005; Lock & Barrett, 2003). Notably however, the mean age of the comparison
groups selected by these researchers (Grade 6 and Grade 9) differed by approximately
five to six years. By comparison, the participants of the current study were drawn
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from three successive school grades (Grades 5, 6, and 7), resulting in a much smaller
age range across the total sample. It is likely that the lack of difference between
grades reflects the similarity between grades of children of upper primary school age,
relative to the greater heterogeneity between upper primary school-aged children and
early high school-aged children, as highlighted by the earlier research (Barrett, Lock
et al., 2005; Lock & Barrett, 2003).
In terms of secondary outcome measures, male gender predicted greater
reductions in peer problems, whereby boys were more likely to have fewer difficulties
with peers following the intervention. Furthermore, boys from Grades 5 and 6
demonstrated greater improvements in social self-esteem relative to girls, whilst there
was no significant difference in improvement in social self-esteem between boys and
girls in Grade 7. The findings suggest that boys from younger grades felt more liked
by their peers than girls and older boys, post-intervention. It would be useful to
conduct further longitudinal research to examine whether these gender and age
differences disappear over time, given that significant changes in self-esteem
collapsed across the total sample were not evident until 12 months follow-up.
Baseline anxiety was found to be a significant predictor of improvement in
internalising symptoms, such that children in the at-risk group at pre-intervention
demonstrated greater reductions in both anxiety and depressive symptomatology.
This finding is consistent with earlier research demonstrating that children with higher
levels of pre-intervention anxiety tend to report greater reductions in both anxiety and
depression post-intervention (Barrett, Lock et al., 2005). These findings have
important implications, particularly with regards to anxiety intervention within low
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SES communities. Given that socioeconomic disadvantage is a risk factor for anxiety
and depression, the finding that children at risk for anxiety respond most positively to
the intervention suggests that curriculum-based anxiety prevention is ideal for these
populations. It was also found that, within the at-risk group, male gender predicted
greater reductions in internalising symptoms. This finding is important, given that
boys are less inclined to report anxiety difficulties than girls (Bell-Dolan, Last, &
Strauss, 1990; Essau & Peterman, 2001; Muris, Merckelbach, Meyer, & Meesters,
1998; Silverman & Treffers, 2001; Silverman, Greca, & Wasserstein, 1995).
Therefore, the current study indicates that participation in school-based anxiety
prevention programs may be very effective for anxious boys, whose difficulties may
otherwise not come to the attention of parents and teachers.
Significant relationships were also identified between several psychosocial
variables at pre-intervention, and anxiety and depressive symptomatology at post-
intervention. Children with higher self-reported emotional problems prior to the
intervention showed greater reductions in both anxiety and depressive
symptomatology post-intervention. This is consistent with earlier reported findings
that children with higher levels of pre-intervention anxiety experienced the greatest
improvements in internalising symptoms. Furthermore, lower social self-esteem and
school self-esteem at pre-intervention was predictive of significantly decreased
depression post-intervention, highlighting self-esteem as a possible mediator for
intervention effectiveness. Lastly, greater use of behavioural avoidance pre-
intervention predicted greater improvement in both anxiety and depressive
symptomatology post-intervention. This finding reflects an existing theorised
connection between avoidant coping and anxiety (Barrett, Rapee, et al., 1996;
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Herman-Stahl & Petersen, 1996; Lengua, et al., 1999; Prior, et al., 2000), and further
research should examine whether the modification of either positive or maladaptive
coping skills may mediate the intervention effect on internalising symptoms.
Clinical Implications
The current study is the first to examine the effectiveness of the universal
school-based delivery of the FRIENDS for Life program within a socioeconomically
disadvantaged population. In conducting research exclusively within a low SES
community, this study addresses the gap in literature on the prevention of childhood
anxiety. It follows only two earlier studies which have examined anxiety prevention
programs exclusively within disadvantaged communities (Misfud & Rapee, 2005;
Roberts, et al., 2010), both of which evaluated alternative intervention protocols to the
FRIENDS program. The findings indicate that the FRIENDS program was successful
in reducing anxiety and depression in children in this population, who are at greater
risk of psychopathology. This finding has important implications for the
implementation of childhood anxiety interventions in low SES communities.
Specifically, it appears that the treatment dosage afforded by the universal delivery of
FRIENDS for Life is sufficient to produce meaningful decreases in internalising
symptoms, despite the increased prevalence of anxiety symptomatology within these
populations.
The significance of the above findings is strengthened by results
demonstrating that the above treatment gains were maintained 12 months post-
intervention. The only other published evaluation of universal anxiety prevention in
disadvantaged schools failed to demonstrate any long-term treatment effects (Roberts,
141
et al., 2010). It therefore provides further evidence of the protective effect afforded
by the FRIENDS for Life program, and demonstrates for the first time that long-term
symptom reduction is possible when intervening with children from disadvantaged
communities at the universal level.
This study expanded on the standard prevention evaluation model by
examining predictors of outcome other than those solely related to anxiety and
depressive symptoms. Specifically, measures assessing the use of positive coping
skills (assistance seeking and cognitive behavioural problem solving), maladaptive
coping skills (cognitive avoidance and behavioural avoidance) self-esteem (social self
esteem and school esteem), and other psychosocial factors (emotional problems, peer
problems, conduct problems, hyperactivity/inattention, and pro-social behaviour)
were employed to provide a broader picture of intervention effectiveness. This
improves on the work conducted by both of the previously published studies
evaluating childhood anxiety prevention in disadvantaged communities, affording a
more complete report of the benefits attributable to universal prevention.
Furthermore, an examination of associations between these secondary outcome
measures and improvement in internalising symptoms offers some insight into what
factors predict a more positive outcome. These results provide an impetus for
additional research, to determine what aspects of the program may be most useful in
improving emotional resilience in children from disadvantaged communities.
The current research employed a considerably larger sample size than either of
the two earlier studies conducted in low SES communities, consisting of children
from three different school grades, as compared to two grades (Misfud & Rapee,
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2005) and one grade (Roberts, et al., 2010). In comparing this study with the only
other universal study in this field (Roberts, et al., 2010), the percentage of children in
the current sample identified as at-risk of anxiety and depression (based on scores on
the SCAS and CDI) was notably higher than that identified by the earlier study. This
is notable, given that Roberts, et al. (2010) employed the same measures, and used a
slightly more conservative cut-off score on the CDI. Arguably then, the constellation
of difficulties faced by children in the current sample may more accurately reflect
those of a population at risk, which gives further credence to the significant
intervention effects revealed in this study.
Previous research has investigated the application of a ‘train-the-trainer’
model with regards to the FRIENDS program, with studies demonstrating that
FRIENDS is effective when delivered by classroom teachers trained to facilitate the
program (Barrett & Turner, 2001; Lowry-Webster, et al., 2001). Indeed, there is
evidence to suggest that teacher-led interventions may be associated with greater
improvements in anxiety symptomatology than those interventions run by mental
health professionals (Neil & Christensen, 2009). Whilst this study did not compare
program effectiveness based on different types of facilitators, the positive results do
provide further support that teacher-led interventions are associated with significant
improvements in anxiety and depression in children. Given the increased prevalence
of anxiety symptomatology within disadvantaged populations, such a comparison may
be an interesting research endeavour for the future, to determine whether a program
delivered by mental health professionals would enhance treatment gains further in this
needy population.
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Limitations
A significant limitation of this study was the lack of a wait-list control
condition, which was denied ethical clearance for two reasons. Firstly, substantial
evidence for the effectiveness of the FRIENDS program when delivered at the
universal level has already been provided by previous research (Barrett, Lock et al.,
2005; Barrett & Turner, 2001; Barrett, et al., 2006; Lock & Barrett, 2003; Lowry-
Webster, et al., 2001; Lowry-Webster, et al., 2003; Stallard, et al., 2008; Stallard et
al., 2007). Secondly, the three schools involved in this research were selected on the
basis of their location within a region of socioeconomic disadvantage. Due to the
increased risk of psychopathology faced by children from disadvantaged
communities, it was deemed unethical to deny children the opportunity to participate
in an empirically validated anxiety prevention program.
The lack of a wait-list comparison condition in the present study limits the
interpretability of the results, given that it cannot be inferred that the intervention is
solely responsible for the significant improvement in levels of anxiety and depression.
The potential influence of both placebo and maturation effects cannot be conclusively
discounted as factors in the significant improvement in anxiety and depressive
symptoms over time. The use of a comparison group, whereby half of the participants
completed an alternative program to the FRIENDS protocol, would have provided
another element of comparison in lieu of a wait-list group. Unfortunately however,
the inclusion of an additional active condition would have proven too resource and
labour-intensive for the current research, and was not within the project scope
required for a doctoral thesis.
144
A second limitation of this study relates to the psychometric measures used in
the research, and the related implications for interpretation of results. Levels of
anxiety and depression were assessed using self-report measures, rather than by
clinical interview, therefore levels of anxiety and depression must be discussed in
terms of symptomatology rather than diagnosable disorders. Some earlier studies
have incorporated a diagnostic clinical interview, such as the ADIS-C (Silverman &
Albano, 1996) in the assessment package (Barrett, 1998; Dadds, et al., 1999; Lock &
Barrett, 2003; Lowry-Webster, et al., 2003), which allows for more conclusive
discussion of anxiety and depression based on diagnostic prevalence. Unfortunately,
due to financial constraints and known challenges inherent in obtaining parental
consent for interviewing children, conducting diagnostic interviews was not feasible
within the scope of this thesis. Accordingly, changes in diagnostic status cannot be
evaluated. Future research should endeavour to incorporate diagnostic interviewing
to more conclusively establish the effectiveness of this intervention within
disadvantaged populations.
A related limitation is that the results of this study are based solely on
children’s subjective self-reporting of symptoms. There may therefore be some
question as to the accuracy of results. Again, due to the financial and personnel
constraints associated with longitudinal universal prevention research, this study did
not incorporate any parent or teacher self-report measures of child functioning.
Undoubtedly, these measures would have provided useful collateral information to
further gauge the effectiveness of the intervention, and provided greater scope for
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statistical evaluation. As such, future researchers in this area would do well to collect
data from multiple sources.
Perhaps the key limitation of the current study was the significant portion of
missing data across all three time-points, meaning that results must be interpreted
with caution. The degree of missing data rendered the use of data imputation
techniques (such as multiple imputation or expectation maximisation) inappropriate
for use with the current study, limiting the range of statistical analyses able to be
performed. Missing data in universal school-based intervention research is a
relatively common problem, and significant rates have been reported in several other
universal evaluations of the FRIENDS program (Barrett, Lock et al., 2005; Lock &
Barrett, 2003; Stallard, et al., 2008). It is probable that the proportion of missing data
was due largely to the characteristics of the population sample. Specifically, data
collection was likely complicated by issues such as increased rates of absenteeism due
to truancy or family difficulties, and the greater tendency of families in this region to
relocate and change schools, due in part to residential and employment instabilities.
Additionally, given the increased involvement of child safety organisations within this
region, it is also possible that missing data may be due to some parents being
suspicious of the purpose the questionnaires.
It is also important to note the issue of missing data within participants,
whereby some children completed some questionnaire measures and not others, at any
given time point. This may be related to the rate of learning difficulties and disruptive
behaviour disorders such as ADHD within the sample population. Efforts were made
to manage this by ensuring all assessment sessions were facilitated by two adults, with
146
all questions read aloud to avoid issues relating to poor reading ability. However, as
most assessment sessions were conducted in classroom groups of approximately 25 to
30 students, thorough supervision of all participants’ progress was impossible. It is
also likely that missing data within participants was an artefact of the assessment
process, which necessitated the completion of the questionnaire package over a week-
long period, rather than all at once. It is possible that the proportion of missing data
may have been lessened by conducting the complete questionnaire battery during one
session, though admittedly this would have been a time-intensive exercise, and
potentially tiring and frustrating for the children. Whilst endeavours were made to
maximise consistency of the assessment phase both within and between schools, the
individual structure, staff availability, and timetabling issues of each school presented
obvious barriers to ensuring a uniform process.
Future Directions
Research into the universal prevention of childhood anxiety is still in its
infancy; the very first published evaluation of intervention at a universal level is
scarcely 10 years old (Barrett & Turner, 2001), and there remains much work to be
done in this field. In particular, the dearth of studies investigating prevention of
childhood anxiety in socioeconomically disadvantaged communities must be
addressed. Individuals in these communities have been shown to be most at risk of a
range of adverse psychosocial factors, not least of which is clinical anxiety. In the
interest of minimising the disease burden of internalising disorders on a macro level,
priority must be directed to prevention, especially in high-risk populations. Further
evaluation of the FRIENDS program within disadvantaged schools may provide
impetus for this program to eventually be implemented as part of the curriculum
147
within such schools. This initiative would overcome the many barriers to mental
health services faced by those families who most require help.
Future evaluations of childhood anxiety prevention in socioeconomically
disadvantaged regions should strive to overcome what is arguably the most inherent
challenge in universal school-based prevention – missing data. Whilst issues such as
increased absenteeism and residential instability in these populations are not easily
overcome, greater data integrity may be achieved by ensuring that participants
complete the questionnaire battery within one session. This would necessarily require
more planning and personnel, and may be facilitated by selecting fewer, or more
succinct assessment measures. Additionally, reductions in missing data may be
achieved by providing incentives for children to complete the questionnaires, such
token rewards (for example, stickers), or enjoyable activities such as computer time,
free play, or sports games in lieu of classroom time. Such initiatives would require
greater collaboration between the research team and the schools involved, to
determine a mutually appropriate option that does not heavily compromise class time.
Another option may be to provide a significant prize, such as a family pass to a theme
park. Children may be more motivated to fully complete their questionnaires if they
are eligible to win such a prize.
The current study focused exclusively on intervention outcomes in three
disadvantaged schools within an urban geographical area. Whilst further studies in
urban regions are required to highlight the value of implementing programs such as
FRIENDS for Life into the school curriculum, future research should also focus on
evaluating potential similarities and differences in program effectiveness between
148
urban and rural disadvantaged schools. Such work would build on the existing small
body of research investigating the impact of internalising disorders in rural school
children (Lyneham & Rapee, 2007; Roberts, Kane, Thomson, Bishop, & Hart, 2003).
A related project may be an evaluation of the FRIENDS program within both urban
and rural indigenous school communities, which are typically disadvantaged on many
levels. A comparison of program outcomes between urban, rural, and indigenous
children may provide useful information to help optimise programs such as FRIENDS
for Life for special needs populations, by adopting a more tailored, and culturally
appropriate approach.
An additional suggestion for future research is to evaluate the longitudinal
effects of universal, school-based anxiety prevention for socioeconomically
disadvantaged populations beyond 12 months follow-up. Past research has
established that the positive gains associated with the FRIENDS program are retained
up to 3 years post-intervention for students commencing the intervention during late
primary school years (Barrett, et al., 2006). However, this research was not
conducted within disadvantaged communities. Given the increased hardships,
challenges and traumas typically faced by individuals from these communities, it
would be interesting to determine whether the resilience benefits afforded by the
intervention are enough to buffer against such experiences over the long term.
Since the commencement of this study, a number of positive measures of
psychosocial functioning have become available for use in prevention research.
These measures assess factors such as hopefulness, self-efficacy, life satisfaction,
social support and resilience. The ‘new generation’ of research into the FRIENDS
149
program is incorporating such measures into their questionnaire batteries, and
published results are eagerly anticipated. Future prevention research should
endeavour to incorporate not only traditional measures of symptomatology and
functioning deficits, but also these more positive ‘strengths-based’ measures, to
provide a more thorough picture of program effectiveness. Future studies should also
strive to gather data from additional sources, rather than just the study participants.
Such sources include classroom teachers and parents, who can provide collateral
information to provide a broader view of program effectiveness.
Whilst efforts were made to keep parents informed of the program
components of the current study, the active involvement of parents in the intervention
was not a major priority of this research. There is evidence demonstrating that
clinically significant reduction in childhood anxiety is possible, independent of
parental involvement in interventions (Kendall, 1994). However, given that later
research has pointed to the benefits of involving parents in the treatment component
(Barrett, Dadds, & Rapee, 1996), the goal of increasing parental involvement in
universal prevention may be a key aspect of future research. In terms of research with
disadvantaged communities, increasing parental engagement is likely to be a
challenging task. However, given the increased risk of psychopathology to both
adults and children in such communities, it would be interesting to determine whether
the involvement of parents may produce greater improvements in child functioning, as
well as additional benefits to parents.
150
Summary
The present study was the first to examine the efficacy of the FRIENDS for
Life program delivered as a universal school-based intervention specifically within a
socioeconomically disadvantaged community. The results indicate that the
intervention was associated with robust, long-term reductions in internalising
symptoms, in conjunction with significant improvements in self-esteem, coping skills,
and other aspects of psychosocial functioning. This research suggests that
intervention at a universal level is sufficient to produce significant reductions in
anxiety and depression symptoms in children from disadvantaged communities,
despite the increased risk of internalising disorders faced by individuals in these
communities. Socioeconomically disadvantaged regions remain an ignored
population in universal childhood anxiety prevention research, and there is scope for
much additional work in this field. Recommendations for future research include
investigating the long-term effectiveness of anxiety prevention programs given the
increased risks in these communities, as well as comparisons between urban and rural
or indigenous disadvantaged populations. Future researchers should also strive to
incorporate measures of positive psychosocial functioning, and to obtain information
from multiple sources, to provide a more complete picture of program effectiveness
for children from socioeconomically disadvantaged communities.
151
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211
Appendix
This Appendix contains the questionnaire battery used in the current research. This
battery was administered at pre-intervention, post-intervention, and 12 months follow-up.
Questionnaire names are provided for the convenience of those reading this document,
however questionnaire names were omitted from the battery completed by participants.
INFORMATION ABOUT THE

QUESTIONNAIRES
These questionnaires form part of an ongoing project at the University of

Queensland. We are interested in understanding how kids think and feel,
and how kids cope with difficult situations in their lives. Most of the
questionnaires in the booklet ask you about yourself, some ask a little bit
about your family. Remember that everything you write on these
questionnaires is confidential! These questions are only going to be seen
by some researchers at the University of Queensland – not anyone in your
family, or anyone at school. This means that no one will ever know what
you write, so please be as honest as possible when answering these
questions.
This is not a test, so there are no right or wrong answers. It’s just about
what you think and feel. Please remember to tell us the truth. There is
no point in being silly because it wastes our time, and it wastes your time!
As we go through the questionnaires, please listen to, and read all

instructions very carefully. Some of the questions or instructions might
seem a little difficult, so please put up your hand and ask for help if you
need to. Remember these questions are about you, so it is important that
you don’t speak to other students when you are filling in answers.
Please remember to answer every question, and if you have any trouble,
put up your hand and we will come and help you.
Thank you very much for filling in these questionnaires!!!
212
Your name: ______________________________
Your school: ______________________________
Your grade: ______________________________
Your age: ______________________________
What is your nationality: __________________________
What is your parents nationality: ______________________
What is your mother’s job: __________________________
What is your father’s job: ___________________________
Please tick who lives with you in your house?
 Mother  Stepmother
 Father  Stepfather
 Sister - how many?  Stepsister - how many?
 Brother - how many?  Stepbrother - how many?
 Grandmother
 Grandfather
 others (please tell us who)
213
Strengths & Difficulties Questionnaire (SDQ)

For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would
help us if you answered all items as best you can, even if you are not absolutely certain.
Please give your answers on the basis of how things have been for you over the last six
months.
Not Somewhat Certainly

True True True
1 I try to be nice to other people. I care about their feelings □ □ □
2 I am restless, I cannot stay still for long □ □ □
3 I get a lot of headaches, stomach-aches, or sickness □ □ □
4 I usually share with others, for example CDs, games, food □ □ □
5 I get very angry and often lose my temper □ □ □
6 I would rather be alone than with people of my age □ □ □
7 I usually do as I am told □ □ □
8 I worry a lot □ □ □
9 I am helpful if someone is hurt, upset or feeling ill □ □ □
10 I am constantly fidgeting or squirming □ □ □
11 I have one good friend or more □ □ □
12 I fight a lot. I can make other people do what I want □ □ □
13 I am often unhappy, depressed, or tearful □ □ □
14 Other people my age generally like me □ □ □
15 I am easily distracted, I find it difficult to concentrate □ □ □
16 I am nervous in new situations, I easily lose confidence □ □ □
17 I am kind to younger children □ □ □
18 I am often accused of lying or cheating □ □ □
19 Other children or young people pick on me or bully me □ □ □
20 I often volunteer to help others (parents, teachers, children) □ □ □
21 I think before I do things □ □ □
I take things that aren’t mine from home, school or
22
elsewhere □ □ □
23 I get along better with adults than with people my own age □ □ □
24 I have many fears, I am easily scared □ □ □
25 I finish the work I’m doing, my attention is good □ □ □
214
Self Esteem Questionnaire (SEI)
If the sentence describes how you usually feel, circle “Like Me”.
If the sentence does not describe how you usually feel, circle “Unlike Me”.
1. I find it very hard to talk in front of the class Like Me Unlike Me
2. I’m a lot of fun to be with Like Me Unlike Me
3. I’m popular with kids my own age Like Me Unlike Me
4. Kids usually follow my ideas Like Me Unlike Me
5. I often feel upset in school Like Me Unlike Me
6. Most people are better liked than I am Like Me Unlike Me
7. I often get discouraged at school Like Me Unlike Me
8. I’m easy to like Like Me Unlike Me
9. I proud of my schoolwork Like Me Unlike Me
10. I’m doing the best work I can Like Me Unlike Me
11. I would rather play with children younger than I am Like Me Unlike Me
12. I like to be called on in class Like Me Unlike Me
13. I’m not doing as well in school as I’d like to Like Me Unlike Me
14. I don’t like to be with other people Like Me Unlike Me
15. Kids pick on me very often Like Me Unlike Me
16. My teachers make me feel I’m not good enough Like Me Unlike Me
215
Children’s Depression Inventory (CDI).
Kids sometimes have different feelings or ideas. This form lists different
feelings and ideas in groups. From each group, pick one sentence that best
describes you in the past two weeks. Put a cross like this X next to your answer.
Let’s try the first one as an example. Put a cross next to the
answer that describes you best.
I read books all the time

I read books once in a while
I never read books
O.K. Let’s go and do the rest of them now.
1. I am sad once in a while

I am sad many times
I am sad all the time
2. Nothing will ever work out for me

I am not sure if things will work out for me
Things will work out for me O.K.
3. I do most things O.K.

I do many things wrong
I do everything wrong
4. I have fun in many things

I have fun in some things
Nothing is fun at all
216
Remember to put a cross next to the answer

that describes you best!!!
5. I am bad all the time

I am bad many times
I am bad once in a while
6. I worry about bad things happening to me once in a while

I worry that bad things will happen to me
I am sure that terrible things will happen to me
7. I hate myself
I do not like myself
I like myself
8. All bad things are my fault

Many bad things are my fault
Bad things are not usually my fault
9. I feel like crying everyday

I feel like crying many days
I feel like crying once in a while
10. Things bother me all the time

Things bother me many times
Things bother me once in a while
217

11. I like being with people

I do not like being with people many times
I do not want to be with people at all
12. I cannot make up my mind about things

It is hard to make up my mind about things
I make up my mind about things easily
13. I look O.K.

There are some bad things about my looks
I look ugly
14. I have to push myself all the time to do my schoolwork

I have to push myself many times to do my schoolwork
Doing schoolwork is not a big problem
15. I have trouble sleeping every night

I have trouble sleeping many nights
I sleep pretty well
16. I am tired once in a while

I am tired many days
I am tired all the time
218

17. Most days I do not feel like eating

Many days I do not feel like eating
I eat pretty well
18. I do not worry about aches and pains

I worry about aches and pains many times
I worry about aches and pains all the time
19. I do not feel alone

I feel alone many times
I feel alone all the time
20. I never have fun at school

I have fun at school only once in a while
I have fun at school many times
21. I have plenty of friends

I have some friends but I wish I had more
I do not have any friends
22. My schoolwork is all right

My schoolwork is not as good as before
I do very badly in subjects I used to be good in
219

23. I can never be as good as other kids

I can be as good as other kids if I want to
I am just as good as other kids
24. Nobody really loves me

I am not sure if anybody loves me
I am sure that somebody loves me
25. I usually do what I am told

I do not do what I am told most times
I never do what I am told
26. I get along with people

I get into fights many times
I get into fights all the time
220
Revised Children’s Manifest of Anxiety Scale (RCMAS)
Read each question carefully. Circle the word “YES” if you think it is
true about you. Put a circle around the word “NO” if you think it is
not true about you.
1. I have trouble making up my mind …………………………………………… Yes No

2. I get nervous when things do not go the right way for me … Yes No
3. Others seem to do things easier than I can …………………………… Yes No
4. I like everyone I know ………………………………………………………………… Yes No
5. Often I have trouble getting my breath ………………………………… Yes No
6. I worry a lot of the time …………………………………………………………… Yes No
7. I am afraid of a lot of things …………………………………………………… Yes No
8. I am always kind …………………………….…………………………………………… Yes No
9. I get mad easily …………………………………………………………………………… Yes No
10. I worry about what my parents will say to me ……………………… Yes No
11. I feel that others do not like the way I do things ……………… Yes No
12. I always have good manners ……………………………………………………… Yes No
13. It is hard for me to get to sleep at night ..………………………… Yes No
14. I worry about what other people think of me ..…………………… Yes No
15. I feel alone even when there are people with me .………………… Yes No
16. I am always good …………………………………………………….…………………… Yes No
17. Often I feel sick in my stomach …..………………………………………… Yes No
18. My feelings get hurt easily ………...…………………………………………… Yes No
19. My hands feel sweaty ……………………..……………………………………… Yes No
20. I am always nice to everyone ……………………….………………………… Yes No
21. I am tired a lot …………………………….…………………………………………… Yes No
22. I worry about what is going to happen ………………………………… Yes No
23. Other people are happier than I am ……………………………………… Yes No
24. I tell the truth every single time …………………………………………… Yes No
25. I have bad dreams ………………………………………………………….………… Yes No
26. My feelings get hurt easily when I am yelled at ………………… Yes No
27. I feel someone will tell me I do things the wrong way ……… Yes No
28. I never get angry ……………………….……………………………………………… Yes No
29. I wake up scared some of the time ……………………………………… Yes No
30. I worry when I go to bed at night …………….………………………… Yes No
31. It is hard for me to keep my mind on my schoolwork ………… Yes No
32. I never say things I shouldn’t ………………………………………………… Yes No
221
Read each question carefully. Circle the word “YES” if you think it is
true about you. Put a circle around the word “NO” if you think it is
not true about you.
33. I wiggle in my seat a lot ……………………….………………………………… Yes No

34. I am nervous ………………………………………………………………………………… Yes No
35. A lot of people are against me ………………………………………………… Yes No
36. I never lie ……………………………………………………………….…………………… Yes No
37. I often worry about something bad happening to me ……… Yes No
222
Spence Child Anxiety Scale (SCAS)
Please tick the box under the word that shows how often each of these things
happen to you. There are no right or wrong answers.
Never Sometimes Often Always
1. I worry about things
2. I am scared of the dark
3. When I have a problem, I get a funny

feeling in my stomach
4. I feel afraid
5. I would feel afraid being on my own at home
6. I feel scared when I have to take a test
7. I feel afraid if I have to use public toilets

or bathrooms
8. I worry about being away from my parents
9. I feel afraid that I will make a fool of

myself in front of people
10. I worry that I will do badly in my schoolwork
11. I worry that something awful will happen to

someone in my family
12. I suddenly feel as if I can’t breathe when

there is no reason for this
13. I have to keep checking that I have done

things right (like the switch is off, or the door is locked)
223
Please tick the box under the word that shows how often each of
these things happen to you.
14. I feel scared if I have to sleep on my own
15. I have trouble going to school in the mornings

because I feel nervous or afraid
16. I am scared of dogs
17. I can’t seem to get bad or silly thoughts

out of my head
18. When I have a problem, my heart beats

really fast
19. I suddenly start to tremble or shake when

there is no reason for this
20. I worry that something bad will happen to me
21. I am scared of going to the doctor or dentist
22. When I have a problem, I feel shaky
23. I am scared of being in high places or lifts

(elevators)
24. I have to think of special thoughts (like

numbers or words) to stop bad things from happening
25. I feel scared if I have to travel in the car,

or on a bus or train
224
26. I worry what other people will think of me
27. I am afraid of being in crowded places

(like shopping centres, the movies, buses, busy playgrounds)
28. All of a sudden I feel really scared for no

reason at all
29. I am scared of insects or spiders
30. I suddenly become dizzy or faint when there

is no reason for this
31. I feel afraid if I have to talk in front of my

class
32. My heart suddenly starts to beat too quickly

for no reason
33. I worry that I will suddenly get a scared

feeling when there is nothing to be afraid of
34. I am afraid of being in small closed spaces,

like tunnels or small rooms
35. I have to do some things over and over again

(like washing my hands, cleaning, or putting things in a certain order)
36. I get bothered by bad or silly thoughts or

pictures in my mind
225

37. I have to do some things in just the right
way to stop bad things happening
38. I would feel scared if I had to stay away

from home overnight
226
Coping Scale for Children and Youth (CSCY)
All children and have some problems they find hard to deal with and
that upset them or worry them. We are interested in finding out what
you do when you try to deal with a hard problem. Think about some
problem that has upset you or worried you in the past few months. It
could be a problem with someone in your family, a problem with a
friend, a school problem or anything else. Briefly describe what the
problem is in the space below:
Listed below are some ways that children and teenagers try to deal
with their problems. Please tell us how often each of these statements
has been true for you when you tried to deal with the problem you
described above. Please circle your response.
Never Sometimes Often Very

often
1. I asked someone in my family
for help with the problem. 1 2 3 4
2. I thought about the problem
and tried to figure out what I 1 2 3 4
could do about it.
3. I tried not thinking about the
problem. 1 2 3 4
4.I stayed away from things that
reminded me about the problem. 1 2 3 4
5. I got advice from someone
about what I should do. 1 2 3 4
6. I took a chance and tried a
new way to solve the problem. 1 2 3 4
7. I went on with things as if
nothing was wrong. 1 2 3 4
227

often
8. I tried not to feel anything
inside me. I wanted to feel 1 2 3 4
numb.
9. I shared my feelings about
the problem with another 1 2 3 4
person.
10. I made a plan to solve the
problem 1 2 3 4
and then I followed the plan.
11. I pretended the problem
wasn’t very important to me. 1 2 3 4
12. I went to sleep so I wouldn’t
have to think about it. 1 2 3 4
13. I kept my feelings to
myself 1 2 3 4
14. I went over in my head some
of the things I could do about 1 2 3 4
the problem.
15. I knew I had lots of feelings
about the problem, but I just 1 2 3 4
didn’t pay attention to them.
16. When I was upset about the
problem, I was mean to someone 1 2 3 4
even though they didn’t deserve
it.
17. I realised there was nothing
I could do. I just waited for it to 1 2 3 4
be over.
18. I tried to get away from the
problem for a while by doing 1 2 3 4
other things.
19. I hoped that things would
somehow work out so I didn’t do 1 2 3 4
anything.
228

often
20. I learned a new way of 1 2 3 4
dealing with the problem
21. I pretended the problem had
nothing to do with me. 1 2 3 4
22. I decided to stay away from
people and be by myself. 1 2 3 4
23. I tried to figure out how I
felt about the problem. 1 2 3 4
24. I tried to pretend that the
problem didn’t happen. 1 2 3 4
25. I figured out what had to be
done and then I did it. 1 2 3 4
26. I tried not to be with anyone
who reminded me of the 1 2 3 4
problem.
27. I tried to pretend that my
problem wasn’t real. 1 2 3 4
28. I put the problem out of my
mind. 1 2 3 4
29. I thought about the problem

in a new way so that it didn’t 1 2 3 4
upset me as much.
229

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The prevention of childhood anxiety in socioeconomically disadvantaged communities:

A universal school-based trial

The prevention of childhood anxiety in socioeconomically disadvantaged communities:

A universal school-based trial

A dissertation submitted for the degree of Professional Doctorate in Clinical Psychology

School of Psychology - University of Queensland

Date: 17th June 2010

I would like to express my eternal gratitude to my supervisor, Dr Paula Barrett, for

The issue of childhood anxiety is magnified in areas of socioeconomic disadvantage,

Results indicated significant reductions in anxiety and depressive symptomatology

Declaration of originality …..……………………………………………………………ii

ADHD Attention-Deficit Hyperactivity Disorder

CHAPTER ONE: CHILDHOOD ANXIETY DISORDERS

community. To address issues of accessibility, many researchers have focused on the

Whilst preventative interventions for anxiety have been validated extensively in

exclusively on the prevention of childhood anxiety disorders in communities of recognised

overrepresented in socioeconomically disadvantaged communities, with both adults and

populations understandably presents greater methodological challenges, it is unfortunate that

most from such interventions in the long term.

issue of childhood anxiety within socioeconomically disadvantaged communities. The

primary goal of this study is to investigate the effectiveness of a universal school-based

the primary outcome measure of anxiety symptomatology, but additionally depressive

The aim of the current chapter is to provide an overview of anxiety in school-aged

children, through investigating prevalence rates, epidemiology and comorbidity of childhood

of childhood anxiety, in terms of psychological wellbeing and psychosocial functioning.

development of cognitive behavioural therapy (CBT) as an individual therapy for anxiety, to

comprehensive review of the shift from treatment to prevention of childhood anxiety. It

Anxiety is a normal and evolutionarily adaptive emotional response to a real or

involve three primary components: physiological (e.g. heightened autonomic responses),

development, and sources of anxiety in childhood and adolescence vary as a function of

later childhood and adolescence, anxiety is more likely to be triggered by challenging

of normative anxiety contexts and developmentally appropriate fear in assessing anxiety in

necessarily constitute disordered functioning.

become problematic when they persistently occur in response to an unreasonable perception

Peterman, 2001). In this way, anxiety ceases to be adaptive, resulting in functional

distress, or more implicitly through poor concentration and irritability. Behavioural

avoidance of anxiety-provoking stimuli is also common, in conjunction with a range of

emotional, academic, and vocational domains.

of childhood anxiety upon other spheres of psychosocial functioning.

community and clinical populations.

criteria for a second, concurrent disorder. Comorbidity in generalised anxiety disorder

problem, resulting in a more complex constellation of difficulties for anxious children.

depressive disorders than with either attention-deficit hyperactivity disorder (ADHD),

The negative impact of comorbid anxiety and depression in childhood is typically

comorbid anxiety and depression are at a distinct disadvantage. In research conducted by

severity of anxiety of symptoms, than those with anxiety alone.

Comorbidity of anxiety and depressive disorders is not always concurrent; a temporal

anxiety disorders in children may longitudinally predict the development of depressive

approximately 64% of adolescents with diagnosable anxiety went on to develop a secondary

demonstrating anxiety symptomatology in children predicts higher levels of depressive

school performance. Ialongo, Edelsohn, Werthamer-Larsson, Crockett, and Kellam (1995)

were more prone to educational underachievement in young adulthood (Woodward &

childhood anxiety may continue to resonate over time.

Another aspect of functioning which is compromised by childhood anxiety is that of

(Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1994). Broadly speaking,

reinforcement and exacerbation of existing anxiety.

1994). Similarly, anxiety disorders in childhood are predictive of depression in later

prevalence rate of 30% for post-traumatic stress disorder (PTSD), in a population of

associated with childhood anxiety include conduct problems, personality psychopathology,

et al., 2004; Weissman et al., 1999).

highlighting the increased risk of more entrenched internalising psychopathology in children

underachievement and vocational limitations.

It is irrefutable that anxiety is a significant mental health problem in childhood, both