School-based prevention of anxiety and depression: a pilot study in Sweden

Risk Factors in Depression and Anxiety Disorders from the Framework of Developmental Psychopathology

Depression and anxiety disorders are among the most prevalent psychiatric disorders that negatively affect individuals’ life in many ways. Understanding how these highly comorbid emotional disorders develop and persist might guide prevention, intervention, and treatment studies. Some common vulnerability factors underlie depression and anxiety disorders. Developmental psychopathology deals with these vulnerabilities and risk factors from a lifetime perspective. The aim of this review is to present the risk factors associated with depression and anxiety from the perspective of developmental psychopathology. For this purpose, we discussed genetic and biological factors, temperament, negative childhood experiences, family and peer relationships, and some cognitive and emotional factors as risk factors. Also, we discussed how these risk factors lead to depression and anxiety disorders. This review emphasizes that some common transdiagnostic risk factors underlie emotional disorders and highlights the importance of a developmental psychopathology perspective to understand the developmental pathways of depression and anxiety disorders.

Building Emotional Resilience in Youth in Lebanon: a School-Based Randomized Controlled Trial of the FRIENDS Intervention

In Lebanon, approximately one in four adolescents suffers from a psychiatric disorder. Alarmingly, 94% of adolescents with a mental disorder have not sought any treatment. This study assessed the effectiveness of an evidence-based school-based universal mental health intervention (the FRIENDS program) in reducing depression and anxiety symptoms in middle school students in Lebanon. A total of 280 6th graders aged 11-13 years were recruited from 10 schools in Beirut. Schools were matched on size and tuition and randomly assigned to intervention or control groups. The FRIENDS program was translated into Arabic, adapted, and then implemented by trained mental health professionals during 10 classroom sessions over 3 months. We assessed sociodemographic and relevant psychological symptoms by self-report, using the Scale for Childhood Anxiety and Related Disorders (SCARED), Mood and Feelings Questionnaire (MFQ), and Strengths and Difficulties Questionnaire (SDQ), at baseline. We re-administered these scales at 3 months post-intervention. There was a significant time × group interaction for the SDQ emotional score (p = 0.011) and total MFQ score (p = 0.039) indicating significant improvement in depressive and emotional symptoms in the intervention group. Subgroup analysis by gender showed a significant time × group interaction for the total SCARED score (p = 0.025) in females but not in males (p = 0.137), consistent with a reduction of anxiety symptoms in this stratum of the intervention group as compared with the control group. The FRIENDS program was effective in reducing general emotional and depressive symptoms among middle school students in this Lebanese study population. This intervention provides an opportunity for promoting mental health in Lebanese schools and reducing the treatment gap in mental health care.

Cognitive behaviour therapy-based early intervention and prevention programme for anxiety in South African children with visual impairments

Background

Anxiety is the most common psychological difficulty reported by youth worldwide and may also be a significant problem for children with visual impairments. Cognitive behaviour therapy (CBT) interventions have proven to be successful in treating childhood anxiety; however, mostly these are not suitable for children with visual impairments, as the materials used are not sufficiently accessible to this population.

Objectives

The present study was motivated by the dearth of research on this topic and aimed to examine the effects of a specifically tailored, group-based, universally delivered, CBT intervention for anxiety in children with visual impairments and to examine the influence of three predictor variables (i.e. age, gender and level of visual impairment) on prevention effects.

Method

A randomised wait-list control group design with pre-, post- and follow-up intervention measures was employed. The final sample of 52 children (aged 9–14) with varying degrees of visual impairment received the anxiety intervention. Participants were followed over a course of 10 months during which their anxiety symptoms were assessed quantitatively at four time points (T1–T4).

Results

The results indicated that the anxiety intervention did not significantly decrease symptoms of anxiety within the intervention groups. However, the intervention appeared beneficial for girls, younger children and legally blind participants.

Conclusion

This study demonstrated how CBT interventions can be adapted for use in children with visual impairments. Results obtained provide a foundation upon which future updated anxiety intervention programmes can be built, meeting the need for further research in this area.

Prevenção de Ansiedade Infantil a partir do Método Friends

Resumo Os Transtornos de Ansiedade têm se desenvolvido com mais frequência em crianças em idade escolar, prejudicando sua saúde, relações sociais e desenvolvimento global. Atualmente, tem-se buscado a prevenção desses transtornos. O Método FRIENDS, programa que visa prevenir ansiedade e depressão por meio do desenvolvimento de habilidades socioemocionais, resiliência e comportamentos para uma vida saudável, é uma possibilidade de intervenção. Nesse contexto, esta pesquisa objetivou verificar se a sintomatologia de ansiedade de crianças diminui após a participação destas no Método FRIENDS. Participaram do estudo 19 crianças, com idades entre 5 e 7 anos, de ambos os sexos. Foi utilizado como instrumento de avaliação o Spence Children’s Anxiety Scale, respondido pelos pais em pré-teste, pós-teste e follow up. Os dados foram comparados a partir de estatística descritiva e inferencial. Os resultados apontam para a diminuição do total de sintomas de ansiedade nas crianças que participaram do método logo após e no seguimento de dois meses.

Treatment Integrity and Social Validity of the FRIENDS for Life Programme in a Northeastern Canadian School System

The FRIENDS for Life (FFL) programme, a school-based anxiety prevention programme, targets anxiety reduction and resiliency development in elementary school-aged children (Barrett, Sonderegger & Xenos, 2003). In the context of equivocal effectiveness findings regarding FFL in Canadian schools, the present study assessed pre–post changes in anxiety, self-esteem, and prosocial behaviour in a school system in Northeastern Canada. To yield further insight to the potential sources of equivocal FFL effectiveness findings, we also evaluated FFL treatment integrity (TI) and social validity (SV). Few studies have assessed FFL TI at the level of identifying which programme sessions, or within-session content, have or have not been adhered to (Higgins & O'Sullivan S, 2015). Similarly, few studies have provided detailed programme SV data or perceived programme benefits by children and parents. TI and SV can provide programme data beyond anxiety reduction, which is key in prevention programming research, as pre–post changes are challenging to detect in ‘healthy’ samples (Durlak & Wells, 1997). Treatment outcome, TI, and SV data were collected from classrooms across 10 elementary schools administering FFL. The sample included 210 child and 108 parent participants; post-testing occurred 1 week following FFL programme completion. Findings indicated significant decreases from pre- to post-test in child-reported anxiety and self-esteem but no changes in prosocial behaviours. Findings suggest that low TI ratings may have impacted anxiety, self-esteem, and prosocial behaviour results, and that child-reported SV may be more related to programme outcomes than parent-reported SV. Implications for FFL programme developers and future FFL evaluation studies are discussed.

Cognitive Behavioural Therapy for Anxiety Disorders in Young Children: A Dutch Open Trial of the Fun FRIENDS Program

Anxiety disorders in young children are highly prevalent and increase the risk of social, school, and familial problems, and also of psychiatric disorders in adolescence and adulthood. Nevertheless, effective interventions for this age group are lacking. One of the few available interventions is the Fun FRIENDS program. We examined whether young children with anxiety disorders showed less anxiety after participating in Fun FRIENDS. Twenty-eight clinically anxious children (4–8 years old) participated in the cognitive behavioural Fun FRIENDS program. The program consists of 12 weekly 1.5-hour sessions and was provided in groups of 3 to 5 children. At preintervention and direct postintervention, parents completed the Anxiety Disorders Interview Schedule for Children and Child Behavior Checklist. Clinically and statistically significant decreases were found in number of anxiety disorders, symptom interference, emotional and behavioural problems, internalising problems, and anxiety problems. The decrease in anxious/depressed problems and externalising problems was not significant. Furthermore, higher preintervention anxiety levels predicted more treatment progress, whereas sex and age did not. The Dutch version of Fun FRIENDS is promising in treating anxiety disorders in young children. Randomised controlled trials are needed to draw definite conclusions on the effectiveness of Fun FRIENDS in a clinical setting.

Long-Term Outcome of a Cluster-Randomized Universal Prevention Trial Targeting Anxiety and Depression in School Children

The present study concerns a 3-year follow-up of a universal prevention trial targeting anxiety and depressive symptoms in school children. In addition to evaluating the long-term effect of the prevention program, we also examined attrition and its effect on the outcome. High rates of attrition have commonly been observed in studies in the field. However, the role of attrition is not sufficiently understood regarding internal and external validity biases. The current study comprised 695 children (aged 8-11 at baseline) from 17 schools in Sweden. Schools were cluster-randomized to either the intervention or control condition. Children completed measures of anxiety and depressive symptoms and parents completed measures of their child's anxiety and general mental health. We found no evidence of long-term effects of the prevention program, except for a small effect regarding parent reports of child anxiety. However, that effect was not found to be of clinical significance. Regarding attrition, children with missing data at the 3-year follow-up displayed higher levels of psychiatric symptoms at baseline and increasing symptoms across time. Furthermore, children in the control condition with missing follow-up data were found to be significantly deteriorated across time compared to the corresponding children in the intervention condition regarding depressive symptoms and total difficulties. In other words, attrition served as a moderator of the effect, which suggests that the overall result was biased toward a null-result. Our study highlights that large and nonrandom attrition severely limits the validity of the results. Further, given the common problem of retaining participants in long-term evaluations of school-based prevention trials, previous studies may suffer from the same limitations as the current study.

School-based prevention of anxiety using the "My FRIENDS" emotional resilience program: Six-month follow-up

Anxiety-related problems are common in childhood and adolescence and, if left untreated, may hold short-term and long-term negative consequences for psychosocial functioning and other domains. In addition to having negative individual-level consequences, anxiety-related problems may have a negative impact at the school level. Because almost all children and adolescents attend school, school plays a significant role in development as a socialisation agent and provides an ideal venue for the delivery of prevention and intervention programs. Here, we present the first evidence regarding the effectiveness of the My FRIENDS emotional resilience program as a method of reducing anxiety among students in Slovenia and the feasibility of implementing the program at the national level. Grade 8 students (N = 78) were assigned either the intervention condition, the My FRIENDS program, or a no-treatment control condition. We measured general anxiety and its components using the AN-UD (Lestvica anksioznosti za učence in dijake) anxiety scale and internalising difficulties using the Strengths and Difficulties Questionnaire at preintervention, postintervention, and 6-month follow-up assessments. Students in the intervention condition reported lower amounts of general anxiety and its cognitive component of worrying, and fewer internalising difficulties at the postintervention and follow-up assessments.

Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects

Anxiety and depression are highly comorbid and share several common etiological processes. Therefore, it may be more efficient to develop interventions that treat or prevent these problems together rather than as separate entities. The present meta-analytic review examined whether interventions for children and adolescents that explicitly targeted either anxiety or depression showed treatment specificity or also impacted the other outcome (i.e. cross-over effects). We addressed this question both within the same type of study (i.e. treatment, prevention) and across study types. Only randomized controlled trials (RCTs) that assessed both constructs with dimensional measures were included in this review. For treatment studies, RCTs targeting anxiety (n = 18) showed significant effects on both anxious and depressive symptoms, although more strongly on anxiety than depression; similarly, RCTs treating depression (n = 9) yielded significant effects on both depressive and anxious symptoms, but stronger effects on depression than anxiety. Thus, there were cross-over effects in treatments purportedly targeting either anxiety or depression, and also treatment specificity, such that larger effects were seen for the target problem at which the treatment was aimed. Anxiety prevention studies (n = 14) significantly affected anxious, but not depressive symptoms, indicating no cross-over effect of anxiety prevention trials on depression. For depression prevention studies (n = 15), the effects were not significant for either depressive or anxiety symptoms, although the effect was significantly larger for depressive than for anxious symptoms. Post-hoc analyses revealed that the effect on depressive symptoms was significant in depression preventions trials of targeted but not universal samples. Implications for transdiagnostic interventions are discussed.

Child, Teacher and Parent Perceptions of the FRIENDS Classroom-Based Universal Anxiety Prevention Programme: A Qualitative Study

School-based mental health prevention programmes can be effective but their adoption within schools will depend on their social acceptability. We report a qualitative evaluation summarising the views of children (115), parents (20) and school staff (47) about a universal school-based anxiety prevention programme FRIENDS. This study was conducted as part of a large scale randomised controlled trial (n = 1362) involving 40 schools in the UK providing primary education to children aged 7-11. Reported overall experience of the programme was very positive, with all three major components of the cognitive behaviour therapy programme (emotional, cognitive, and behavioural) being accepted well and understood by children. The programme was considered to be enjoyable and valuable in teaching children important skills, particularly emotional regulation and coping. Children provided examples of using the skills learned during FRIENDS to manage their emotions and solve problems. However, teachers were concerned that the programme overlapped with the current school curriculum, required additional time and almost half were unable to identify any tangible changes in the children's behaviour. Whilst this paper provides evidence to support the social validity of the FRIENDS anxiety prevention programme, the concerns raised by teachers question the longer-term sustainability of the programme.