The Treatment of Anxiety in Young

Children: Results of an Open Trial of

the Fun FRIENDS Program
Paula Barrett,1 Brian Fisak2 and Marita Cooper3
1 University of Queensland, Brisbane, Queensland, Australia
2 University of Central Florida, Orlando, Florida, USA
3 Australian National University, Canberra, Australian Capital Territory, Australia

Background: Preschool-aged children exhibit a relatively high prevalence rate of

anxiety disorders, and the course of these disorders is often chronic. However,
surprisingly few studies have focused on the treatment of anxiety in this age group.
In response to this limitation, the purpose of the current study was to examine
the effectiveness of an open trial of the Fun FRIENDS (FF) program, a downward
extension of the FRIENDS programs for preschool-aged children (5–7 years), in
a community clinic setting. Method: The sample included 31 children diagnosed
with an anxiety disorder. Treatment consisted of 10 weekly sessions administered
in a group format. Parents also received two information sessions. Child anxiety,
behavioural inhibition, and resiliency were assessed at preintervention, immediate
postintervention, and at 12-month follow-up. Results: Significant decreases in child
anxiety and shyness and improvements on measures of resiliency were observed
following the completion of treatment. Conclusions: The results of this study provide
support for the effectiveness of the Fun FRIENDS program as a treatment for anxiety
in young children. Further, this study adds to the relatively small body of research
focused on the use of CBT to treat anxiety disorders in this population.

 Keywords: anxiety, child, preschool, early intervention, internalising

Anxiety disorders are among the most common psychiatric disorders in children
(Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015), and early intervention efforts
may be of particular importance, as many children develop anxiety symptoms dur-
ing the preschool years (Egger & Angold, 2006; Paulus, Backes, Sander, Weber, &
Gontard, 2015). Further, anxiety disorders in young children tend to persist and lead
to impairment in a number of areas of functioning (Bufferd, Dougherty, Carlson,
Rose, & Klein, 2012; Hirshfeld-Becker & Biedermann, 2002; Towe-Goodman, Franz,
Copeland, Angold, & Egger, 2014; Wichstrøm, Belsky, & Berg-Nielsen, 2013). De-
spite the relatively high prevalence, persistence, and level of impairment associated
with anxiety in young children, surprisingly few studies have focused on anxiety in
this population.
Cognitive-behavioural therapy (CBT) has been identified as the gold standard of 231
child and adolescent anxiety treatment (Barrett, Lowry-Webster, & Turner, 2000;
James, Soler, & Weatherall, 2009; Kendall, 1990, 1994). Although these treatments
have been well established in school-aged children, relatively few studies have focused

Address for correspondence: Marita Cooper, The Friends Programs International Foundation Pty Ltd, PO Box
5699, West End QLD 4101, Australia. Email research@friendsprograms.com
Behaviour Change Volume 32 Number 4 2015 pp. 231–242 
c The Author(s) 2015
doi 10.1017/bec.2015.12
 Paula Barrett, Brian Fisak and Marita Cooper

on the treatment of anxiety in preschool-aged children. Recently, Hirshfeld-Becker

et al. (2010) examined the effectiveness of a CBT program for 4- to 7-year-old chil-
dren diagnosed with an anxiety disorder. The intervention included direct parent- and
child-based intervention, and significant clinical improvements were found from pre-
to immediate postintervention. In a second study, Donovan and March (2014) ex-
amined the efficacy of an online CBT program to treat anxiety in preschool children.
This parent-based intervention also yielded positive results. Finally, Monga, Rosen-
bloom, Tanha, Owens, and Young (2015) compared the effectiveness of a parent-only
treatment to a combined parent- and child-treatment condition. Although treatment
gains were found in both groups, the parent-child treatment group exhibited greater
gains at immediate postintervention and follow-up. The findings from Monga et al.
highlight the importance of child-based intervention in this age group.
Overall, although results from initial trials are promising, more research is needed
to assess the effectiveness of CBT for anxiety disorders in preschool-aged children.
One possible treatment option is the Fun FRIENDS program, which was developed
as a downward extension of the FRIENDS for Life program for 4- to 7-year-old
children (Barrett, 2007a, 2007b). Five areas of social and emotional learning are
addressed during the program: (1) developing a sense of self, (2) social skills, (3)
self-regulation, (4) responsibility for others, and (5) prosocial behavior. Further, this
program was designed so that it can be delivered across the prevention-treatment
spectrum, ranging from universal prevention intervention to treatment for children
diagnosed with anxiety disorders.
A number of differences between the Fun FRIENDS program and the above-
mentioned preschool anxiety CBT programs are noteworthy. First, clinical interven-
tions for anxiety in young children focus primarily on strategies to reduce current
symptomology. In contrast, the Fun FRIENDS program has a dual focus on reducing
current symptomology and promoting protective factors in order to prevent the on-
set and progression of future psychopathology, including the promotion of resilience
and wellbeing. Second, although the program does include two parent sessions, a
unique component of the program is that it is primarily a child-based intervention.
Further, the Fun FRIENDS program was designed for dissemination and widespread
use (Barrett, 2007a).
Two published studies have examined the effectiveness of Fun FRIENDS as a
universal prevention intervention. Consistent with the concept of universal preven-
tion, both of these studies included children, regardless of risk status. In the first
study, Pahl and Barrett (2010) evaluated the efficacy of the Fun FRIENDS program
in 263 preschool children. The program, implemented by teachers trained to ad-
minister the program, was conducted in nine preschools across Brisbane, Australia.
While the study showed no significant differences between the intervention group
and waitlist condition at immediate postintervention, the intervention group demon-
strated significant improvements in anxiety symptomology, behavioural inhibition,
232 and socio-emotional competence at 12-month follow-up. Non-significant findings at
immediate postintervention may be explained by the observation that universal pro-
grams (programs administered to individuals regardless of risk status) often yield small
effect sizes at immediate postintervention (Neil & Christensen, 2009). In particular,
many participants in universal programs exhibit minimal symptomology at the onset
of the study, and long-term follow-up may be needed to assess the ability of a pro-
gram to prevent the gradual emergence of symptoms in some participants over time
(Gillham, Shatté, & Reivich, 2001).

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 Effectiveness of the Fun FRIENDS Program

More recently, Anticich, Barrett, Silverman, Lacherez, and Gillies (2013) com-
pleted a randomised trial with 488 preschool-aged children. Participants in the Fun
FRIENDS group exhibited significantly greater improvements in behavioural inhibi-
tion, behavioural difficulties, and socio-emotional competence relative to comparison
groups at immediate postintervention and at 12-month intervention.
Overall, despite promising results of the Fun FRIENDS program, the two trials
to date were universal interventions in school settings, and the effectiveness as a
treatment in a community setting has yet to be examined.
The purpose of the current study was to examine the effectiveness of the Fun
FRIENDS program as a CBT treatment for preschool-aged children diagnosed with an
anxiety disorder. It was hypothesised that, based on the results of an open trial, children
would demonstrate improvement in measures of child anxiety, shyness, and resilience.
Exploratory analyses were also planned, including examination of the predictors of
treatment outcome and the impact of the program on parental functioning.

Method
Participants
Families enrolling in the Fun FRIENDS program at a community clinic were ap-
proached to participate in the study. In order to be included in the study, children
were required to be between the ages of 4 and 7 and were required to meet criteria for
at least one anxiety disorder, based on a semistructured clinical interview. Utilising
this inclusion criteria, a total of 31 children and their parents were recruited and
agreed to participate. An additional 18 children were treated at the clinic but not
included in the trial as they did not meet diagnostic criteria for an anxiety disorder.
The mean age of the participants in the program was 5.68 (SD = 0.54), and the group
comprised of 12 females and 19 males. The age range of participants was 5–7 years.
Participation was voluntary, and the study was conducted in accordance with ethical
standards for human subject’s research in Australia.

Measures
In addition to a demographics questionnaire, a semi-structured diagnostic interview
and a number of self-report measures to assess parent and child functioning were com-
pleted by parents at three different time points (preintervention, immediate postin-
tervention, and 12-month follow-up). These measures are listed below.

Measures Child Functioning

Anxiety Disorders Interview Schedule for Children (ADIS-C).The ADIS-C (Silver-
man & Nelles, 1988) is a semi-structured diagnostic interview designed to assess the
presence of an anxiety disorder or other internalising disorder based on DSM-IV-TR
criteria. The ADIS-C has been found to possess strong interrater reliability regarding
determination of principal diagnosis (α = 0.92) and individual anxiety disorders (α = 233
0.8–1.0; Lyneham, Abbott, & Rapee, 2007). The ADIS-C interviews were conducted
with the parents by trained clinical psychologists or masters’ level clinicians via tele-
phone. In order to reduce experimenter bias, participant pre- and postintervention
interviews were not conducted by the same interviewer.
The Preschool Anxiety Scale (PAS). The PAS is a 34-item parent-rating scale as-
sessing childhood anxiety symptoms in younger children (Spence, Rapee, McDonald,

Behaviour Change
 Paula Barrett, Brian Fisak and Marita Cooper

& Ingram, 2001). The PAS is a modified version of the Spence Children’s Anxiety
Scale (Spence, 1997). A total score calculated from the PAS, along with five subscale
scores (separation anxiety, physical injury fears, social anxiety, obsessive compulsive
disorder, and generalised anxiety). The PAS also includes six items to assess trauma
and posttraumatic stress symptomology, which are not included in the total score. The
PAS is scored on a continuous scale, and higher scores are indicative of higher levels
of anxiety-related symptoms. Psychometric studies have demonstrated support for the
five factor model of preschool anxiety, and the instrument has demonstrated strong
correlations with other measures of internalising problems (Spence et al., 2001).

The Behavioral Inhibition Questionnaire (BIQ). The BIQ is a parent-report in-

strument measuring behavioural inhibition in their children (BI; Bishop, Spence, &
McDonald, 2003). The BIQ has been found to possess strong internal consistency
(α = .96 for parent report and teacher report) and strong convergent validity with
the Preschool Age Psychiatric Assessment — Behavioral Inhibition subscale and the
Children’s Behavior Questionnaire — Shyness subscale (Kim et al., 2011).

Behavioral and Emotional Rating Scale (BERS). The BERS is a parent-report mea-
sure designed to assess children’s emotional and behavioural strengths (Epstein &
Sharma, 1998). The 52-item instrument evaluates the five domains of functioning,
including interpersonal strength, family involvement, intrapersonal strength, school
functioning, and affective strength. The BERS has been found to have excellent in-
terrater reliability (r > .83) and moderate-to-excellent test–retest reliability ranging
from .53 to .99 (Epstein, Harniss, Ryser, & Pearson, 1999).

The Strengths and Difficulties Questionnaire (SDQ). The SDQ is a brief screening
measure that assesses behavioural difficulties and competencies in children aged 3–16
years (Goodman, 1997). The instrument evaluates attributes across the five domains of
emotional difficulties (conduct problems, hyperactivity/inattention, peer relationship
problems, and prosocial behavior). The SDQ has been shown to possess good specificity
and moderate sensitivity in identifying psychiatric diagnoses for both community
and clinical populations (Goodman, Ford, Simmons, Gatward, & Meltzer, 2000;
Goodman, Renfrew, & Mullick, 2000).

Measures of Parent Functioning

The Hospital Anxiety and Depression Scale (HADS).The HADS is a 14-item mea-
sure assessing symptomology related to anxiety and depression over the previous week
(Zigmond & Snaith, 1983). Originally developed as a brief screening measure for
physicians, the instrument assesses items related to depression (predominantly ex-
periences of anhedonia) and generalised anxiety (Snaith, 2003). The HADS has
demonstrated good internal consistency and has been found to be a robust measure
234 across both clinical and community samples (Mykletun, Stordal, & Dahl, 2001).

The Parenting Stress Index-Short Form (PSI-SF).The PSI-SF (Abidin, 1995) is

comprised of 36 items and is designed to assess levels of stress within the parent–child
relationship. The measure consists of the three subscales of parental distress, parent–
child dysfunctional interaction, and difficult child. The PSI-SF has demonstrated
high internal consistency as well as construct validity with other measures related to
parental stress (Reitman, Currier, & Stickle, 2002).

Behaviour Change
 Effectiveness of the Fun FRIENDS Program

Procedure
Once enrolled in the study, parents were asked to complete the above-mentioned
measures at preintervention, immediate postintervention, and at 12-month follow-
up. The Fun FRIENDS program was implemented by three clinical psychologists at
a community health clinic. Following completion of the intervention, parents were
provided with a psychological report presenting results from pre and post responses on
the ADIS-C. At the 12-month follow-up, parents were offered a free booster session
with a clinical psychologist to discuss any progress or difficulties they had experienced.
The program took place over a time period of approximately 2.5 months.

Intervention
The Fun FRIENDS program (Barrett, 2007a, 2007b) was conducted over 10 weekly
sessions. Utilising play-based activities, skills were delivered via developmentally
appropriate methods over the 1½-hour sessions. In the final 20 minutes of each
session, clinicians met separately with parents to discuss skills introduced during the
session, appropriate reinforcement at home, as well as answer any questions. Each
group was led by one facilitator, and sessions were conducted as outlined in the
Fun FRIENDS Group Leader Manual (Barrett, 2007a). The sessions were delivered in
groups of eight to twelve children. Furthermore, parents were encouraged to attend two
information sessions outlining the program and providing skills to enhance positive
development and reinforce skills taught at home. Each family was provided with the
Family Learning Adventure Workbook (Barrett, 2007b) containing session-by-session
activities. An overview of the interactive group-based activities is provided in Table 1.

Results
Child Anxiety and Shyness
A repeated measures t test was conducted to assess for changes in PAS-total scores
from pre- to immediate postintervention, and a significant decrease in PAS scores
was observed, t(29)= 5.14, p < .01, indicating lower levels of anxiety following
intervention. Due to attrition, a smaller sample size was available at 12-month follow-
up and, as a result, a separate analysis was conducted to examine change in PAS total
scores from preintervention to 12-month follow-up. Based on this analysis, gains were
maintained at 12-month follow-up, t(11) = 4.08, p < .001.
Data from the ADIS were examined as a measure of the presence of anxiety disorder
diagnoses from pre- to immediate postintervention. The mean number of diagnoses
decreased significantly from preintervention, t(29) = 3.80, p < .01; and again, based
on available follow-up data, the effect remained significant from preintervention to
12-month follow-up, t(15) = 5.96, p < .001.
Finally, scores on the BIQ were examined to assess changes in shyness/inhibition
over time. Scores on the BIQ also decreased significantly from pre- to immediate
postintervention, t(28)= 423, p < .001, and the results were maintained at 12-month 235
follow-up, t(13)= 4.54, p < .01 (see Table 2 for group means). Scores are provided in
Table 2.

Measures of Child Resiliency

Potential changes in levels of resiliency were assessed with the BERS and SDQ. Based
on an independent samples t test, BERS scores significantly improved from pre- to

Behaviour Change
 Paula Barrett, Brian Fisak and Marita Cooper

TABLE 1
Outline of the Fun FRIENDS Session Content

Session Content of session — major learning objectives

Session 1 • Developing a sense of identity, introduction to the group, name games.

• Introduction of the concept of ‘being brave’, social skills promotion.
• Acceptance of differences.
Session 2 F: Feelings
• Affective education and identification of various emotions, including
recognition of physiological arousal associated with emotions.
Session 3 F: Feelings (continued)
• How to cope with feelings, thumbs-up ideas (helpful coping behaviours)
and thumbs-down ideas (unhelpful coping behaviours).
• Building on understanding the link between feelings and behaviour.
• Strategies to help others when they experience feelings assists with
development of empathy.
Session 4 R: Remember to relax
• Identification of physiological arousal (‘body clues’) related to anxiety.
• Relaxation strategies are taught including, diaphragmatic breathings
(‘milkshake breathing’), progressive muscle relaxation and visualisation.
Session 5 I: I can try my best!
• Introduction to the cognitive components of the program.
• Children are taught to become aware of and pay attention to their inner
thoughts or self-talk.
• Self-talk is referred to in terms of ‘red’ (unhelpful thoughts) and ‘green’
(helpful thoughts), using the traffic light analogy.
Session 6 I: I can try my best! (continued)
• Introduction to challenging unhelpful red thoughts and come up with
alternative helpful green thoughts.
• Application of green thoughts to help us achieve our goals.
Session 7 E: Encourage
• Try new things by breaking tasks down into small steps and using green
thinking to help achieve goals.
Session 8 N: Nurture
• Introduce idea of role models and support teams, those people who help
us to achieve our goals.
Session 9 D: Don’t forget to be brave
• Support teams continued.
• Planning ahead for difficult situations.
236 Session 10 S: Stay smiling
• Children dress up as their favourite brave person and celebrate their
success in completing the program.
Review Two booster sessions: review of Fun FRIENDS strategies and preparing for
strategies and future challenges.
skills

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 Effectiveness of the Fun FRIENDS Program

TABLE 2
Means and Standard Deviations for Outcome Variables

Pre-Intervention Postintervention

Measure Mean SD Mean SD

PAS 39.83 13.18 29.00 12.79

BIQ 127.79 35.01 108.55 29.02
BERS+ 107.00 18.14 115.87 18.90
SDQ 21.83 4.94 19.07 5.28
ADIS-C 3.00 2.35 1.30 1.80

Note: PAS = total scores on the Preschool Anxiety Scale; BIQ = total scores on the Behavioral Inhibition
Scale; BERS = Behavioral and Emotional Rating Scale; SDQ = Strengths and Difficulties Questionnaire;
ADIS-C = Anxiety Disorder Interview Schedule for Children (value denotes average number of anxiety
disorder diagnoses). + Higher scores indicate improved functioning.

immediate postintervention, t(29)= 4.45, p < .001. Although not significant, scores
from pre- to 12-month-follow-up approached significance, t(13) = 1.92, p = .07.
Scores on the SDQ also improved from pre- to postintervention, t(29) = 3.74, p <
.01. Results were maintained at 12-month follow-up, t(13) = 2.88, p < .05. Means
are provided in Table 2.

Predictors of Treatment Outcome

Demographic variables. Demographic variables, including child gender, child age,
and family income were examined as potential predictors of treatment outcome at im-
mediate postintervention. In particular, a multiple regression analysis was conducted
and each of the predictor variables were entered simultaneously, and the PAS-total
was the designated criterion variable. The model was not significant, R2 = .047,
F(3,26) = .43, p = .73, indicating that child gender, age, and family income were not
associated with treatment outcome at postintervention.

Parent functioning. A series of hierarchical regression analyses were conducted to ex-

amine the degree to which measures of parent functioning at preintervention predicted
level of child anxiety at immediate postintervention, after controlling for preinter-
vention levels of child anxiety. More specifically, separate regression analyses were
conducted for mothers and fathers, and the PAS-total was the designated criterion
variable. Preintervention scores of the PAS were entered as the predictor variable in
the first step of the equation as a covariate, and parent HADS Depression, HADS-
Anxiety, and PSI scores were entered in the second step of the equation. Regarding 237
maternal functioning, the second step did not lead to significant improvement in the
model, ࢞R2 = .05, F(3, 25) = .65, p = .59, indicating that maternal depression,
anxiety, and stress related to the mother–child relationship at preintervention were
not predictors of treatment outcome. Regarding paternal functioning, the second step
did not lead to significant improvement in the model, ࢞R2 = .02, F(3, 19) = .27, p =
.84, indicating that paternal depression, anxiety, and stress related to the father–child
relationship at preintervention did not predict treatment outcome.

Behaviour Change
 Paula Barrett, Brian Fisak and Marita Cooper

The above procedures were repeated to assess the degree to which parent func-
tioning was associated with potential improvements in child resiliency. In particular,
the designated criterion variable was the BERS-total at immediate postintervention.
Preintervention BERS total scores were entered in the first step of the equation as
a covariate, and the HADS-Depression, HADS-Anxiety and PSI-total scales were
entered in the second step of the regression equation. Regarding mother functioning,
the addition of mother HADS and PSI scores did not lead to significant improvement
in the model, ࢞R2 = .046, F(3,25) = 01.44, p = .25. The analysis was repeated with
father HADS and PSI scores entered in the second step of the regression equation.
Again, the addition of second step did not lead to significant improvement in the
model, ࢞R2 = .063, F(3,19) = 2.39, p = .11.
Child anxiety at preintervention. Anxiety severity was examined as a potential pre-
dictor of treatment outcome. In particular, an independent samples t test was con-
ducted to determine if children in the intervention condition with higher levels of
anxiety exhibited greater decreases in anxiety from pre- to postintervention, when
compared to children with lower levels of anxiety. First, a median split on the PAS
was conducted to classify children as either high or low anxiety. Next, change scores
were calculated by subtracting PAS total scores at preintervention from PAS total
scores at immediate postintervention. A significant difference was found for change
scores in the high when compared to the low anxiety groups, t(28) = -2.09, p <
.05. In particular, the higher anxiety group exhibited a greater reduction in PAS
scores from pre- to postintervention, with mean change from pre- to postinterven-
tion of 15 points (SD = 12.30) when compared to the change exhibited by lower
anxiety group, with a mean change of 6.67 points (SD = .37). These findings sug-
gest that the intervention was particularly beneficial for children with more severe
anxiety.
The above analysis was repeated to determine whether level of anxiety predicted
the magnitude of change in resilience from pre- to postintervention, as measured
by the BERS. The differences in the magnitude of change scores was not signif-
icant, t(44) = 1.74, p = .09, suggesting participants in the intervention group
experienced equal improvements in resilience regardless of level of resilience at
baseline.

Discussion
The purpose of this study was to evaluate the effectiveness of the Fun FRIENDS pro-
gram in the treatment of clinically anxious preschool-aged children. It was hypothe-
sised that significant decreases in child anxiety symptoms and shyness and improve-
ments in resilience would be observed following the completion of the intervention.
This hypothesis was supported, as significant decreases in anxiety and shyness were
reported from pre- to immediate postintervention. In addition, a significant decrease
238 in the number of anxiety disorder diagnoses, as measured by the ADIS-C, was reported
from pre- to immediate postintervention. Further, improvements were found in chil-
dren’s resiliency from pre- to immediate postintervention, as measured by the BERS
and SDQ. Attrition led to limitations on the conclusions that can be made about the
efficacy of the program at 12-month follow-up; however, based on the available data,
gains were maintained over this time interval. Finally, based on an examination of
predictors of treatment outcome, the program was found to be particularly beneficial
to children with higher levels of anxiety.

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 Effectiveness of the Fun FRIENDS Program

It is noteworthy that these findings add to a surprisingly relatively small number of

studies focused on the treatment of anxiety disorders in young children (Donovan &
March, 2014; Hirshfeld-Becker et al., 2008; Monga et al., 2015). In addition to adding
to a relatively small body of research, the findings from this study provide a number of
unique contributions to the research literature. More specifically, in addition to the
focus on the reduction of current anxiety symptomology, the Fun FRIENDS program
is unique because it also focuses on the promotion of protective factors, including
resilience and wellbeing. This is relevant, as resilience and general wellbeing may
be key factors to improving mental health trajectories and maximising the effects of
intervention over longer periods of time (Barrett, Cooper, & Teoh, 2014). Further,
this program is unique as the first program to be primarily a child-based intervention,
and although more research is needed, it appears that direct intervention with children
may be an effective strategy for the reduction of anxiety in anxious preschool-aged
children. Finally, another noteworthy advantage of this program is the availability for
dissemination (Barrett, 2007a).
The results of the current study also add to the evidence for the effectiveness of
the Fun FRIENDS program across the prevention-treatment spectrum. In particu-
lar, the first two published studies focused on the potential effectiveness of the Fun
FRIENDS program as a school-based, universal prevention intervention, meaning
that the program was provided to young children regardless of risk status (Anticich
et al., 2013; Pahl & Barrett, 2010), while the current study is the first to examine
the efficacy of this program as a treatment for clinically anxious children in a clinical
setting.
Despite the strengths and unique contributions of this study, a number of lim-
itations and directions for future research are noteworthy. First, the absence of a
comparison group leads to some limitations in the interpretation of the results. In
particular, regarding pretest–posttest design, certain threats to validity cannot be
completely ruled out, including statistical regression (Shadish, Cook, & Campbell,
2002). Consequently, although the results of the current study are promising, follow-
up studies with comparison groups are needed. In addition, the study relied primarily
on parent report. Although practical limitations provide challenges to the inclusion
of other measures of treatment outcome in community mental health settings, it is
recommended that future studies include other strategies to assess treatment out-
come, including child-report, teacher-report, and observational report. Additionally,
this study would have been improved with the utilisation of measures of treatment
fidelity and social validity, as inclusion of these measures in future studies will en-
sure consistency and accurate adherence to program structure and acceptance of
the program. With this said, it is noted that the Fun FRIENDS program is a man-
ualised program requiring facilitators to complete a one-day training prior to con-
ducting the program, and all facilitators were highly trained clinical psychologists.
Consequently, the intervention was unlikely to deviate greatly from the intended
structure. 239
It is also recommended that future research include a larger sample, which may
allow for a more stable assessment of moderators of treatment outcome. Finally, both
parent-based and child-based interventions have been utilised to treat anxiety in
preschool-aged children, and it is recommended that follow-up studies are conducted
to examine the most effective combination of these interventions. Overall, despite the
above-mentioned limitations, the results of this study provide a promising direction
for the treatment of anxiety in young children.

Behaviour Change
 Paula Barrett, Brian Fisak and Marita Cooper

Acknowledgments
The authors would like to first and foremost thank all of the families who gave their
time and support to complete all of the research questionnaires and processes.

Declaration of Interest
The first author is the program developer for the FRIENDS protocols, including
the Fun FRIENDS program. To manage this conflict, the first author was included
only in supporting the study design process and throughout the writing and editing
procedures. All collection and analysis of data, as well as delivery of the intervention,
were conducted by the remaining authors and research staff.

References
Abidin, R.R. (1995). Parenting Stress Index: Professional manual (3rd ed.). Odessa, FL: Psychological
Assessment Resources, Inc.
Anticich, S.J., Barrett, P.M., Silverman, W., Lacherez, P., & Gillies, R. (2013). The pre-
vention of childhood anxiety and promotion of resilience among preschool aged chil-
dren: A universal school based trial. Advances in School Mental Health Promotion, 6, 93–21.
doi:10.1080/1754730X.2013.784616
Barrett, P.M. (2007a). Fun Friends. The teaching and training manual for group leaders. Brisbane,
Australia: Fun Friends Publishing.
Barrett, P.M. (2007b). Fun Friends. Family learning adventure: Resilience building activities for 4-, 5-,
and 6-year-old children. Brisbane, Australia: Fun Friends Publishing.
Barrett, P.M., Cooper, M., & Teoh, A.B. H. (2014). When time is of the essence: A rationale
for ‘earlier’ early intervention. Journal of Psychological Abnormalities in Children, 3, 133–140.
doi:10.4172/2329-9525.1000133
Barrett, P.M., Lowry-Webster, H., & Turner, C. (2000). FRIENDS anxiety program. Brisbane, Aus-
tralia: Australian Academic Press
Bishop, G., Spence, S.H., & McDonald, C. (2003). Can parents and teachers provide a
reliable and valid report of behavioural inhibition? Child Development, 74, 1899–1917.
doi:10.1046/j.1467-8624.2003.00645.x
Bufferd, S.J., Dougherty, L.R., Carlson, G.A., Rose, S., & Klein, D.N. (2012). Psychiatric disorders
in preschoolers: Continuity from ages 3 to 6. The American Journal of Psychiatry, 169, 1157–1164.
Donovan, C.L., & March, S. (2014). Online CBT for preschool anxiety disorders: A randomised
control trial. Behaviour Research and Therapy, 5824–35. doi:10.1016/j.brat.2014.05.001
Egger, H.L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool chil-
dren: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47,
331–337. doi:10.1111/j.1469-7610.2006.01618.x
Epstein, M.H., Harniss, M.K., Ryser, G., & Pearson, N. (1999). The Behavioral and Emotional
Rating Scale: Test–retest and inter-rater reliability. Journal of Child and Family Studies, 8, 319–
327. doi:10.1023/A:1022067329751
Epstein, M.H., & Sharma, H.M. (1998). Behavioral and Emotional Rating Scale: A strength based
approach to assessment. Austin, TXL PRO-ED
240 Gillham, J.E., Shatté, A.J., & Reivich, K. (2001). Needed for prevention research: Long-term follow
up and the Evaluation of mediators, moderators, and lay providers. Prevention & Treatment, 4,
doi:10.1037/1522-3736.4.1.49c
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child
Psychology and Psychiatry, 38, 581–586. doi:10.1111/j.1469-7610.1997.tb01545.x
Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2000). Using the Strengths and
Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample.
British Journal of Psychiatry, 177, 534–539. doi:10.1192/bjp.177.6.534

Behaviour Change
 Effectiveness of the Fun FRIENDS Program

Goodman, R., Renfrew, D., & Mullick, M. (2000). Predicting type of psychiatric disorder from
Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London
and Dhaka. European Child and Adolescent Psychiatry, 9, 129–134. doi:10.1007/s007870050008
Hirshfeld-Becker, D.R., & Biederman, J. (2002). Rationale and principles for early intervention
with young children at risk for anxiety disorders. Clinical Child and Family Psychology Review, 5,
161–172. doi:10.1023/A:1019687531040
Hirshfeld-Becker, D.R., Masek, B., Henin, A., Blakely, L.R., Pollock-Wurman, R.A., McQuade, J., ...
Biederman, J. (2010). Cognitive behavioral therapy for 4-7-year-old children with anxiety dis-
orders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 78, 498–510.
Hirshfeld-Becker, D.R., Masek, B., Henin, A., Blakely, L.R., Rettew, D.C., Dufton, L., ... Biederman,
J. (2008). Cognitive-behavioral intervention with young anxious children. Harvard Review of
Psychiatry, 16, 113–125. doi:10.1080/10673220802073956
James, A.A., Soler, A., & Weatherall, R.R.W. (2009). Cognitive behavioural therapy for anxiety
disorders in children and adolescents. Cochrane Database of Systematic Reviews 2005, Issue 4.
Art. No.: CD004690. doi:10.1002/14651858.CD004690.pub2
Kendall, P.C. (1990). Coping Cat workbook. Admore, PA: Workbook Publishing.
Kendall, P.C. (1994). Treating anxiety disorders in youth: Results of a randomized clinical trial.
Journal of Consulting and Clinical Psychology, 65, 627–635. doi:10.1037/0022-006X.62.1.100
Kim, J., Klein, D.N., Olino, T.M., Dyson, M.W., Dugherty, L.R., & Durbin, C.E. (2011). Psycho-
metric properties of the Behavioral Inhibition Questionnaire in preschool children. Journal of
Personality Assessment, 93, 545–555. doi:10.1080/00223891.2011.608756
Lyneham, H.J., Abbott, M.J., & Rapee, R.M. (2007). Inter-rater reliability of the Anxiety Disorders
Interview Schedule for DSM-IV: Child and parent version. Journal of the American Academy of
Child and Adolescent Psychiatry, 46, 731–737. doi:10.1097/chi.0b013e3180465a09
Monga, S., Rosenbloom, B.N., Tanha, A., Owens, M., & Young, A. (2015). Comparison of child–
parent and parent-only cognitive-behavioral therapy programs for anxious children aged 5 to 7
years: Short- and long-term outcomes. Journal of the American Academy of Child & Adolescent
Psychiatry, 54, 138–146. doi:10.1016/j.jaac.2014.10.008
Mykletun, A., Stordal, E., & Dahl, A.A. (2001). Hospital Anxiety and Depression (HAD) scale:
Factor structure, item analyses and internal consistency in a large population. The British Journal
of Psychiatry, 179, 540–544. doi:10.1192/bjp.179.6.540
Neil, A.L., & Christensen, H. (2009). Efficacy and effectiveness of school-based preven-
tion and early intervention programs for anxiety. Clinical Psychology Review, 29, 208–215.
doi:10.1016/j.cpr.2009.01.002
Pahl, K.M., & Barrett, P.M. (2010). Preventing anxiety and promoting social and emotional strength
in preschool children: A universal evaluation of the Fun FRIENDS program: A matched-pair
trial. Advances in School Mental Health Promotion, 3, 14–25. doi:10.1080/1754730X.2010.9715683
Paulus, F.W., Backes, A., Sander, C.S., Weber, M., & Gontard, A. (2015). Anxiety disorders and
behavioral inhibition in preschool children: A population-based study. Child Psychiatry and
Human Development, 46, 150–157. doi:10.1007/s10578-014-0460-8
Polanczyk, G.V., Salum, G.A., Sugaya, L.S., Caye, A., & Rohde, L.A. (2015). Annual research
review: A meta-analysis of the worldwide prevalence of mental disorders in children and adoles-
cents. Journal of Child Psychology And Psychiatry, 56, 345–365. doi:10.1111/jcpp.12381
Reitman, D., Currier, R.O., & Stickle, T.R. (2002). A critical evaluation of the Parenting Stress
Index — Short Form (PSI-SF) in a Head Start population. Journal of Clinical Child and Adolescent
Psychology, 31, 384–392. doi:10.1207/S15374424JCCP3103_10 241
Shadish, W.R., Cook, T.D., & Campbell, D.T. (2002). Experimental and quasiexperimental designs for
generalized causal inference. Boston, MA: Houghton Mifflin Company.
Silverman, W., & Nelles, W.B. (1988). The Anxiety Disorders Interview Schedule for Chil-
dren. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 772–778.
doi:10.1097/00004583-198811000-00019
Snaith, R.P. (2003). The Hospital Anxiety and Depression Scale. Health and Quality of Life Outcomes,
1, 29–33. doi:10.1186/1477-7525-1-29.

Behaviour Change
 Paula Barrett, Brian Fisak and Marita Cooper

Spence, S.H. (1997) Structure of anxiety symptoms in children: A confirmatory factor analytic study.
Journal of Abnormal Psychology, 106, 280–297. doi:10.1037/0021-843X.106.2.280
Spence, S.H., Rapee, R., McDonald, C., & Ingram, M. (2001). The structure of anx-
iety symptoms among preschoolers. Behaviour Research and Therapy, 39, 1293–1316.
doi:10.1016/S0005-7967(00)00098-X
Towe-Goodman, N.R., Franz, L., Copeland, W., Angold, A., & Egger, H. (2014). Perceived family
impact of preschool anxiety disorders. Journal of the American Academy of Child & Adolescent
Psychiatry, 53, 437–446. doi:10.1016/j.jaac.2013.12.017
Wichstrøm, L., Belsky, J., & Berg-Nielsen, T.S. (2013). Preschool predictors of childhood anxiety
disorders: A prospective community study. Journal of Child Psychology and Psychiatry, 54, 1327–
1336. doi:10.1111/jcpp.12116
Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica
Scandinavica, 67, 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x

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