Early intervention for childhood anxiety in a school setting: outcomes for an economically disadvantaged population

A randomized controlled trial of cognitive behavioural therapy for managing anxiety in adolescents with acquired brain injury

The aim of this randomized controlled trial was to evaluate an adapted cognitive behavioural therapy (CBT) programme for treating anxiety in adolescents with acquired brain injury (ABI). Participants with ABI (12-19 years, N = 36) recruited from two sites were randomly allocated into either the intervention receiving 11 sessions of CBT (n = 19) or a wait-list control group (n = 17). The primary outcome was participants' anxiety and secondary outcomes were participants' depression, self-perception, and participation in daily activities, and parental stress, measured at (i) pre-intervention, (ii) immediately post-intervention, (iii) 2 months post-intervention and (iv) 6 months post-intervention. Repeated measures ANOVAs revealed significant treatment effects with the intervention group demonstrating greater improvements in self-reported anxiety, as well as self- and parent-reported depression from pre- to immediately post-treatment, compared to wait-list controls. Little evidence of treatment effects was found for the remaining outcomes (parent-reported anxiety, self-perception, daily participation, and parental stress). Significant improvement in self-reported anxiety found immediately post-treatment was maintained at two- and six-month follow-up. Findings provide support for adapted CBT as an effective means of reducing anxious and depressive symptomatology in adolescents with ABI compared to waitlist controls, and offer support for the use of these techniques to manage anxiety in this population.

Predictors of school-based cognitive behavior therapy outcome for youth with anxiety

Meta-analyses of school-based CBT have shown that prevention for anxiety symptoms typically report small but significant effects. There is limited knowledge regarding which youths may benefit most and least from such programs, and characteristics of youth who respond differentially to interventions of different intensity. The present study examined predictors of school-based CBT outcomes among 302 youths (mean age 14.0 years, SD 0.8, 84% female) who participated in a randomized waitlist-controlled trial comparing a 10-session and a 5-session group intervention. Potential predictors included youth and parental factors, and credibility and expectancy of the interventions. Pre-intervention anxiety and depression levels, and clinician rated severity were examined as moderators of intervention effects. Outcomes were youth-, and parent-reported youth anxiety and depressive symptoms at post-intervention and 1-year follow-up. Higher parent-reported impairment from youth anxiety predicted larger parent-reported anxiety and depressive symptom change, whereas higher caregiver strain was associated with less symptom change. Higher parent rated credibility and expectancy was associated with improved outcomes at post-intervention. At 1-year follow-up, no predictors of outcome were identified. No moderators were identified. Families with high levels of caregiver strain associated with youth anxiety may need extra support regardless of length of intervention program. Parents' credibility and expectancy of interventions should be targeted to optimize school-based CBT.

Mental health services in the school environment-Future visions using a phenomenographic approach

AIMS AND OBJECTIVES

First, to describe the variation in stakeholders' perceptions related to the desirable mental health services in school environments. Second, to construct alternative future visions based on these perceptions. Finally, to describe stakeholders' perceptions about the actions needed to reach such an ideal state.

BACKGROUND

The increased need for mental health care has challenged the role of schools and school health care in the area of mental health services for those of school-age. There is a need for future visions and comprehensive statements concerning the mental health services provided in the school environment.

DESIGN

The study was undertaken in Finland, between February 2020 and February 2021. Qualitative individual interviews were conducted with 15 professional stakeholders and focus group interviews with 10 stakeholders advocating for adolescents or parents.

METHOD

The study was conducted with the phenomenographic approach using a visioning methodology. The study is reported following the COREQ checklist.

RESULT

Four alternative future visions were formulated based on the perceptions of the stakeholders. They emphasised different aspects: (1) non-medicalising the school environment, (2) early and extensive intervention by school nurses enabled by work distribution with mental health specialists, (3) a multiprofessional team providing help on overall health questions and (4) a focusing of the services on mental disorders. Necessary changes were identified at the micro-, mezzo- and macro-level.

CONCLUSION

The future visions are based on opposite perceptions related to the mission and focus of school health care. One extreme emphasises overall health promotion for everyone, while the other accentuates treatment for those suffering from mental disorders. The former may lead to inadequate help for mental health problems and the latter insufficient help for other health problems.

RELEVANCE TO CLINICAL PRACTICE

This study contributes alternative future visions, promotes strategic planning and helps to clarify the future role of school nurses.

Leveraging deep learning models to understand the daily experience of anxiety in teenagers over the course of a year

INTRODUCTION

Anxiety disorders are a prevalent and severe problem that are often developed early in life and can disrupt the daily lives of affected individuals for many years into adulthood. Given the persistent negative aspects of anxiety, accurate and early assessment is critical for long term outcomes. Currently, the most common method for anxiety assessment is through point-in-time measures like the GAD-7. Unfortunately, this survey and others like it can be subject to recall bias and do not fully capture the variability in an individual's day-to-day symptom experience. The current work aims to evaluate how point-in-time assessments like the GAD-7 relate to daily measurements of anxiety in a teenage population.

METHODS

To evaluate this relationship, we leveraged data collected at four separate three week intervals from 30 teenagers (age 15-17) over the course of a year. The specific items of interest were a single item anxiety severity measure collected three times per day and end-of-month GAD-7 assessments. Within this sample, 40 % of individuals reported clinical levels of generalized anxiety disorder symptoms at some point during the study. The first component of analysis was a visual inspection assessing how daily anxiety severity fluctuated around end-of-month reporting via the GAD-7. The second component was a between-subjects comparison assessing whether individuals with similar GAD-7 scores experienced similar symptom dynamics across the month as represented by latent features derived from a deep learning model. With this approach, similarity was operationalized by hierarchical clustering of the latent features.

RESULTS

The aim clearly indicated that an individual's daily experience of anxiety varied widely around what was captured by the GAD-7. Additionally, when hierarchical clustering was applied to the three latent features derived from the (LSTM) encoder (r = 0.624 for feature reconstruction), it was clear that individuals with similar GAD-7 outcomes were experiencing different symptom dynamics. Upon further inspection of the latent features, the LSTM model appeared to rely as much on anxiety variability over the course of the month as it did on anxiety severity (p < 0.05 for both mean and RMSSD) to represent an individual's experience.

DISCUSSION

This work serves as further evidence for the heterogeneity within the experience of anxiety and that more than just point-in-time assessments are necessary to fully capture an individual's experience.

An Ounce of Prevention: Building resilience and targeting anxiety in young children

BACKGROUND

Anxiety disorders are among the most common psychiatric disorders in childhood and can develop as early as the preschool years. Therefore, providing young children who display early signs of anxiety with skills to prevent the development of later psychopathology is invaluable. The current study evaluates the effectiveness of Fun FRIENDS, an anxiety prevention and resilience program for young children.

METHOD

Fifty-seven kindergartners across three classrooms participated in a 15-week anxiety prevention program and teachers completed a behavioral screening measure and anxiety questionnaire at pre, post, 3 month, and 10-month follow-up assessment points.

RESULTS

Anxiety positively correlated with emotional symptoms, peer difficulties, and total difficulties at pre-intervention. Anxiety symptoms decreased from pre-intervention to follow-up. Additionally, prosocial behaviors improved and moderated the relationship between pre-and post-intervention anxiety symptoms.

CONCLUSIONS

These findings yield promising implications regarding the effectiveness of prevention and intervention programs on increasing social emotional skills and reducing anxiety symptoms in young children.

Moderators of an intervention on emotional and behavioural problems: household- and school-level parental education

BACKGROUND

Children of lower-educated parents and children in schools with a relatively high percentage of peers with lower-educated parents (lower parental education schools) are more likely to develop emotional and behavioural problems compared to children in higher-educated households and schools. Universal school-based preventive interventions, such as the Good Behaviour Game (GBG), are generally effective in preventing the development of emotional and behavioural problems, but information about potential moderators is limited. This study examined whether the effectiveness of the GBG in preventing emotional and behavioural problems differs between children in lower- and higher-educated households and schools.

METHODS

Using a longitudinal multi-level randomized controlled trial design, 731 children (Mage=6.02 towards the end of kindergarten) from 31 mainstream schools (intervention arm: 21 schools, 484 children; control arm: 10 schools, 247 children) were followed annually from kindergarten to second grade (2004-2006). The GBG was implemented in first and second grades.

RESULTS

Overall, the GBG prevented the development of emotional and behavioural problems. However, for emotional problems, the GBG-effect was slightly more pronounced in higher parental education schools than in lower parental education schools (Bhigher parental education schools =-0.281, P <0.001; Blower parental education schools =-0.140, P = 0.016). No moderation by household-level parental education was found.

CONCLUSIONS

Studies into universal school-based preventive interventions, and in particular the GBG, should consider and incorporate school-level factors when studying the effectiveness of such interventions. More attention should be directed towards factors that may influence universal prevention effectiveness, particularly in lower parental education schools.

The Effects of Cognitive Behavioral Group Therapy on Anxiety and Emotion Regulation in Thai Middle School Students

This quasi-experimental study examined the effects of Cognitive Behavioral Group Therapy (CBGT) in alleviating anxiety and enhancing emotion regulation in community-sample Thai middle school students. Forty-seven community-sample students in Grades 7–9 with elevated SCARED scores participated in this pre-post treatment–control study. Twenty-three in the treatment group attended the eight-session 2-hour semi-weekly CBGT. The remaining were the control group. Before and after the intervention, the participants completed the measures of anxiety and emotion regulation. Data obtained were subsequently analyzed using repeated-measures and between-groups MANOVAs. At post-intervention, the treatment group reported a significant decrease in anxiety but a significant increase in emotion regulation. Furthermore, when compared with the control group, their anxiety score was significantly lower but their emotion regulation score was significantly higher, respectively. Findings supported the benefits of CBGT in reducing anxiety in Thai middle school students and in enhancing their emotion regulation skills. Therapeutic implications for anxiety reduction were discussed.

Minimising young children's anxiety through schools (MY-CATS): protocol for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.

METHODS

The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.

DISCUSSION

The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.

TRIAL REGISTRATION

ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021.

The Cool Kids as a School-Based Universal Prevention and Early Intervention Program for Anxiety: Results of a Pilot Study

The efficacy of the Cool Kids program has been consistently demonstrated both within Australia and internationally, but limited data are available on the use of Cool Kids as a universal program. The purpose of the study is to evaluate Cool Kids as a universal program for preventing childhood anxiety in the school context. There were 73 Italian children (35 boys and 36 girls, ages 10–13 years) attending the last year of primary school and the first year of middle school who participated in an active intervention based on a school adaptation of the Cool Kids protocol. Results of t-test analyses highlighted a downward trend of anxiety symptoms, especially in total anxiety, somatic anxiety, generalized anxiety, separation anxiety, social anxiety and school phobia at post-treatment assessed by children. Even the score of depression symptoms, measured as a second outcome measure, decreased after the treatment. This study contributes to the evidence base for the Cool Kids program as a universal program for preventing childhood anxiety in the school context. Although these preliminary results show some promise, their replication in future research is necessary given current study limitations.

A pilot practice-based outcomes evaluation of low-intensity cognitive behavioural interventions delivered by postgraduate trainees to children and young people with mild to moderate anxiety or low mood: an efficient way forward in mental health care?

Anxiety and depression affect a significant number of children and young people (CYP) and can have a far reaching and long-lasting impact. Cognitive behavioural (CB) interventions can be effective for treating anxiety and depression in CYP but are difficult to access. Recent government policy in England seeks to train a non-traditional graduate workforce to deliver a range of CB interventions for mild to moderate anxiety and depression to CYP, in community settings. This practice-based evaluation aimed to estimate the effectiveness of CB interventions delivered by postgraduate trainees undertaking training in a range of CB interventions for mild to moderate anxiety and depression whilst on placement in schools or community Child and Adolescent Mental Health Services (CAMHS). Self- and parent-reported routine outcome measures (ROMS) were completed pre- and post-intervention, including measures of symptom severity, symptom impact and goal achievement. Significant improvements were demonstrated across all self and parent-reported measures post-intervention, with mean scores falling firmly in the non-clinical range, a significant reduction in the proportion of CYP in the clinical range on measures, and predominantly medium to large effect sizes. Results are promising in terms of the capacity to train a graduate workforce to deliver a range of low-intensity CB interventions to CYP experiencing mild to moderate depression or anxiety-based difficulties in either CAMHS or school settings, increasing capacity across the system. The current practice-based evaluation also supports the potential effectiveness of current training models/programmes. Further research is needed in terms of long-term outcomes and to compare outcomes between settings, interventions, and demographic groups.

Key learning aims

(1)

School-based depression and anxiety prevention programs: An updated systematic review and meta-analysis

Depression and anxiety are often first experienced during childhood and adolescence, and interest in the prevention of these disorders is growing. The focus of this review was to assess the effectiveness of psychological prevention programs delivered in schools, and to provide an update to our previous review from five years ago (Werner-Seidler, Perry, Calear, Newby, & Christensen, 2017). Three electronic databases were systematically searched for published articles of randomised controlled trials (RCTs) evaluating the efficacy of school-based prevention programs until October 2020. There were 130 articles that met inclusion criteria, representing 118 unique trials and 45,924 participants. Small between-group effect sizes for depression (g = 0.21) and anxiety (g = 0.18) were detected immediately post-intervention. Subgroup analyses suggested that targeted prevention programs (for young people with risk factors or symptoms) were associated with significantly greater effect sizes relative to universal programs for depression, which was confirmed by meta-regression. There was also some evidence that external providers conferred some benefit over school-staff delivered programs. Overall, study quality was moderate and no association between risk of bias and effect size was detected. School-delivered psychological prevention programs have small effects in reducing symptoms of depression and anxiety. Refinement of these programs, and knowledge about how they can be sustainably delivered in schools beyond the trial period is now needed for population-level preventive effects. Systematic Review Registration Number: PROPSERO - CRD42020188323.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Treatment Fidelity in Brief Versus Standard-Length School-Based Interventions for Youth with Anxiety

To examine treatment fidelity in a randomized controlled trial of indicated school-based cognitive-behavioral therapy (CBT) delivered in groups to youth with anxiety. We investigated whether adherence and competence (a) differed across brief and standard-length CBT, and (b) if adherence and competence predicted change in anxiety symptoms and impairment. Method: Sessions were observationally coded with the Competence and Adherence Scale for CBT for Anxiety Disorders in Youth. Coders (N = 7) rated 104 sessions from 52 groups delivered by 32 facilitators (M age = 43.2 years, SD = 8.1) to 295 youth (M age = 14.0 years, SD = 0.8). Outcomes were youth- and parent-reported anxiety symptoms and impairment at post-intervention and 1-year follow-up. Linear mixed effect models were used to analyze whether fidelity predicted clinical outcomes. Results: Levels of adherence and competence were adequate in both programs, but higher in brief compared to standard-length CBT p < .001 and p = .010, respectively). Neither adherence nor competence predicted clinical outcomes at any timepoints. Conclusion: Higher levels of adherence and competence in brief CBT suggest that it may be easier for novice CBT providers to achieve fidelity in simplified and less flexible interventions. Contrary to expectation, adherence and competence did not predict clinical outcomes.

A Randomized Controlled Trial of a Cognitive Behavior Therapy Program for Children with Clinical Anxiety Symptoms

High anxiety and anxiety disorders are among the most prevalent mental health problems in children and lead to significant interference with children’s daily functioning. Most empirical evaluations of treatment come from English-language countries. The aim of the present study was to evaluate and replicate the effectiveness of a cognitive-behavioral intervention program to manage anxiety in children among children from Greece. Forty-one children–parent(s) dyads participated in the study. Children were 9–12 years old, with clinically elevated symptoms of anxiety, and they were assigned to either the standard group treatment (cognitive behavior therapy (CBT)) or to a waitlist group (WL). Both children and their parents in the CBT group reported statistically significant reductions in children’s anxiety symptoms at post-intervention and at the 6-month follow-up. A significant reduction was also found in life interference due to anxiety according to both child and parent reports. In contrast, no significant changes in anxiety symptoms or life interference were reported among the WL. The current results support the effectiveness of a CBT program for anxious children from a non-clinic, non-school setting in Greece.

Codesign and development of a primary school based pathway for child anxiety screening and intervention delivery: a protocol, mixed-methods feasibility study

INTRODUCTION

Anxiety difficulties are among the most common mental health problems in childhood. Despite this, few children access evidence-based interventions, and school may be an ideal setting to improve children's access to treatment. This article describes the design, methods and expected data collection of the Identifying Child Anxiety Through Schools - Identification to Intervention (iCATS i2i) study, which aims to develop acceptable school-based procedures to identify and support child anxiety difficulties. METHODS AND ANALYSIS: iCATS i2i will use a mixed-methods approach to codesign and deliver a set of procedures-or 'pathway'-to improve access to evidence-based intervention for child anxiety difficulties through primary schools in England. The study will consist of four stages, initially involving in-depth interviews with parents, children, school staff and stakeholders (stage 1) to inform the development of the pathway. The pathway will then be administered in two primary schools, including screening, feedback to parents and the offer of treatment where indicated (stage 2), with participating children, parents and school staff invited to provide feedback on their experience (stages 3 and 4). Data will be analysed using Template Analysis.

ETHICS AND DISSEMINATION

The iCATS i2i study was approved by the University of Oxford's Research Ethics Committee (REF R64620/RE001). It is expected that this codesign study will lead on to a future feasibility study and, if indicated, a randomised controlled trial. The findings will be disseminated in several ways, including via lay summary report, publication in academic journals and presentation at conferences. By providing information on child, parent, school staff and other stakeholder's experiences, we anticipate that the findings will inform the development of an acceptable evidence-based pathway for identification and intervention for children with anxiety difficulties in primary schools and may also inform broader approaches to screening for and treating youth mental health problems outside of clinics.

The effect of an integrated reading and anxiety intervention for poor readers with anxiety

A recent systematic review has reported that poor reading is reliably associated with anxiety. However, we currently lack evidence-based intervention for children who have both poor reading and anxiety (PRAX). In this study, we tested a new PRAX intervention in 8- to 12-year-old children using a double-baseline intervention case series design. Analyses of both group and individual data revealed that 12 weeks of PRAX intervention significantly improved children's reading and spelling accuracy, and significantly reduced both anxiety disorders and symptoms. These results support PRAX intervention as a treatment for comorbid reading and anxiety problems in children and pave the way to a randomised controlled trial.

Indicated prevention interventions for anxiety in children and adolescents: a review and meta-analysis of school-based programs

Anxiety disorders are among the most common youth mental health disorders. Early intervention can reduce elevated anxiety symptoms. School-based interventions exist but it is unclear how effective targeted approaches are for reducing symptoms of anxiety. This review and meta-analysis aimed to determine the effectiveness of school-based indicated interventions for symptomatic children and adolescents. The study was registered with PROSPERO [CRD42018087628]. We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library for randomised-controlled trials comparing indicated programs for child and adolescent (5-18 years) anxiety to active or inactive control groups. Data were extracted from papers up to December 2019. The primary outcome was efficacy (mean change in anxiety symptom scores). Sub-group and sensitivity analyses explored intervention intensity and control type. We identified 20 studies with 2076 participants. Eighteen studies were suitable for meta-analysis. A small positive effect was found for indicated programs compared to controls on self-reported anxiety symptoms at post-test (g = - 0.28, CI = - 0.50, - 0.05, k = 18). This benefit was maintained at 6 (g = - 0.35, CI = - 0.58, - 0.13, k = 9) and 12 months (g = - 0.24, CI = - 0.48, 0.00, k = 4). Based on two studies, > 12 month effects were very small (g = - 0.01, CI = - 0.38, 0.36). No differences were found based on intervention intensity or control type. Risk of bias and variability between studies was high (I² = 78%). Findings show that school-based indicated programs for child and adolescent anxiety can produce small beneficial effects, enduring for up to 12 months. Future studies should include long-term diagnostic assessments.

The Prevention of Anxiety and Depression in Early Childhood

Recent statistics suggest that anxiety and depressive symptoms and disorders can occur earlier in life than previously thought, and appear to be on the increase. The burden that is associated with internalizing symptoms is large, with children's social, emotional, and cognitive development negatively impacted. Research suggests that early intervention and prevention is vital for adaptive development, and this review set out to explore the literature regarding social-emotional learning programs for children of preschool age that aim to prevent and reduce symptoms of anxiety and depression. The review focused on interventions that could be delivered universally in the school context to children aged 4-6 years or their parents. Only six programs were identified that met these criteria. The results of this review suggest that intervention and prevention efforts in early childhood are needed and can be effective in terms of reducing the burden associated with internalizing symptoms in childhood, at least in the short term. This appears to be the case particularly when parents are actively involved in the intervention, too. However, more rigorous research is needed that involves larger randomized controlled trials with multiple reporters and consistent administration of assessments across the samples.

Providers’ Experiences with Delivering School-Based Targeted Prevention for Adolescents with Anxiety Symptoms: A Qualitative Study

The school setting is important for delivering targeted prevention to adolescents with anxiety. However, schools may not have available providers with training or experience in delivering evidence-based interventions, e.g., school psychologists. Training providers available in the schools, e.g., school nurses, is important. Further, to investigate their experiences in delivering targeted prevention to adolescents with anxiety could help understand factors promoting implementation success. A qualitative study including focus groups with providers of school-based targeted prevention cognitive-behavioral therapy for anxiety in adolescents was conducted. Focus group interviews were audiotaped and transcribed verbatim. Systematic Text Condensation, a method for thematic cross-case analysis was used. The Active Implementation Framework (AIF) was used to contextualize the results. Seventeen providers participated in the study. They reported several facilitators contributing to successful implementation: Their feeling of competence in delivering the interventions were built through skills-based training, supervision, and collegial support. Conducting initial assessment of each adolescent helped the providers individualize the interventions. Seeing positive outcomes in adolescents gave the providers motivation to continue implementation. Further, collaborating with teachers facilitated both recruitment of adolescents and administering group sessions. Minimal leadership-oriented factors were reported. Overall, the findings correspond to some of the drivers in AIF. This study offers providers’ perspectives on implementation of targeted prevention for anxiety in the school setting. Our results show that providers experience mastery in delivery when receiving support, training, and supervision. This seems to be essential facilitators for implementing much needed targeted prevention for youth with anxiety.

Brief, Non-Pharmacological, Interventions for Pediatric Anxiety: Meta-Analysis and Evidence Base Status

In 1998, Ost published [One-session treatment of specific phobias-a rapid and effective method] [in Swedish] giving rise to the idea that brief, intensive, and concentrated psychosocial interventions could exhibit public health impact. At this juncture, and per criteria of the Society for Clinical Child and Adolescent Psychology, there are data supporting that brief, non-pharmacological intervention [prescriptions] for pediatric anxiety can be considered well-established or probably efficacious. In addition, data from 76 randomized controlled trials (N = 17,203 youth) yield an overall mean effect size of 0.19 on pediatric anxiety outcomes (pre-post). Note, however, that effect sizes vary significantly. These data point to the capacity for clinical change coming from in-vivo exposures for specific phobias (~3 h, one session), CBT with social skills training (~3 h, six sessions for indicated prevention and early intervention), and CBT-based parent training (~6 h, eight digital modules with clinician support). Given such evidence, we recommend efforts be made to establish ways to position such treatment innovations for rapid deployment facilitated by high-quality training, monitoring, technical assistance, and ongoing disclosures.

Effectiveness of Brief and Standard School-Based Cognitive-Behavioral Interventions for Adolescents With Anxiety: A Randomized Noninferiority Study

OBJECTIVE

We examined the effectiveness of targeted school-based cognitive-behavioral therapy (CBT) for adolescents (12-16 years of age) with anxiety, and tested whether brief CBT was noninferior to standard duration CBT.

METHOD

A randomized controlled study of 313 adolescents (mean 14.0 years, SD = 0.84, 84% girls) were recruited through school health services to 10 weeks CBT group interventions. Groups of 5 to 8 adolescents were randomly allocated to brief (5 sessions, comprising 5.5 hours) or standard CBT (10 sessions, comprising 15 hours), or 10 weeks waitlist (WL). Self-reported and parent-reported youth anxiety symptoms, impairment from anxiety, depressive symptoms,and clinical severity were assessed pre- and postintervention, after WL, and at 1-year follow-up.

RESULTS

Targeted school based CBT significantly reduced adolescents' anxiety symptoms with small to moderate effect sizes compared to WL (Cohen d = 0.34 for youth report and d = 0.53 for parent report). According to the parents, also adolescents' impairment from anxiety was significantly reduced compared to WL (d = 0.51). Pre to post changes in anxiety symptoms were small to moderate (within-group effect sizes between d = 0.41 and d = 0.67). Although no significant differences in effects were found between brief and standard CBT, brief CBT was not noninferior to standard CBT. Outcomes from both interventions were sustained at 1-year follow-up.

CONCLUSION

Targeted school-based CBT interventions reduced anxiety, impairment, and depressive symptoms in adolescents. Both brief and standard CBT demonstrated efficacy, but brief CBT was not noninferior to standard CBT. By administering school-based CBT to youths with anxiety symptoms, we may reach young people with effective interventions at an earlier phase in their lives.

CLINICAL TRIAL REGISTRATION INFORMATION

School Based Low-intensity Cognitive Behavioral Intervention for Anxious Youth (LIST); http://clinicalrials.gov/; NCT02279251.

School-based early intervention for anxiety and depression in older adolescents: A feasibility randomised controlled trial of a self-referral stress management workshop programme ("DISCOVER")

INTRODUCTION

Schools may provide a convenient intervention setting for young people with mental health problems generally, as well as for those who are unwilling or unable to access traditional clinic-based mental health services. However, few studies focus on older adolescents, or those from ethnic minority groups. This study aims to assess the feasibility of a brief school-based psychological intervention for self-referred adolescents aged 16-19 years.

METHODS

A two-arm cluster randomised controlled trial was conducted in 10 inner-city schools with block randomisation of schools. The intervention comprised a one-day CBT Stress management programme with telephone follow-up (DISCOVER) delivered by 3 psychology (2 clinical and 1 assistant) staff. The control was a waitlist condition. Primary outcomes were depression (Mood and Feelings Questionnaire; MFQ) and anxiety (Revised Child Anxiety and Depression Scale; RCADS-anxiety subscale). Data were analysed descriptively and quantitatively to assess feasibility.

RESULTS

155 students were enrolled and 142 (91.6%) followed up after 3 months. Participants were predominantly female (81%) and the mean age was 17.3 years, with equal numbers enrolled from Year 12 and Year 13. Over half (55%) of students were from ethnic minority groups. Intraclass correlations were low. Variance estimates were calculated to estimate the sample size for a full RCT. Preliminary outcomes were encouraging, with reductions in depression (d = 0.27 CI-0.49 to -0.04, p = 0.021) and anxiety (d = 0.25, CI-0.46 to -0.04, p = 0.018) at follow-up.

CONCLUSIONS

Results support the feasibility of a school-based, self-referral intervention with older adolescents in a definitive future full-scale trial (Trial no. ISRCTN88636606).

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.

Review: Prevention of anxiety among at-risk children and adolescents - a systematic review and meta-analysis

BACKGROUND

Anxiety disorders are common, often start in childhood and run a chronic course. As such there is a need for effective prevention.

METHODS

We conducted a systematic review and meta-analyses of randomized, controlled trials to prevent the onset of anxiety disorders in 'at risk' young people. Diagnostic and symptom outcomes were examined. Putative moderators were tested as was publication bias.

RESULTS

We included 16 trials (2545 young people). Two trials reported diagnostic outcomes, and significant effects were found for these at end-of-programme (RR = .09, 95%CI = .02 to .16), 6- (RR = .17, 95%CI = .06 to .27) and 12-month (RR = .31, 95%CI .17 to .45) follow-ups. Based on 16 trials, improved anxiety symptoms were significant compared to nonattention controls only, with small effect sizes reported by young people at the end-of-programmes, 6- and 12-month follow-ups; and by parents at the end of the programmes and 12-, but not 6-, month follow-ups. There was no evidence of significant moderation or publication bias.

CONCLUSIONS

Fourteen studies included children and young people who presented with elevated anxiety symptoms, but anxiety disorder was not ruled out in the participants in these studies. Hence, these studies might be reporting results of mixed prevention/early intervention programmes. Prevention programmes that target developmental risk factors, not only disorder maintaining factors, appear most promising. The clinically meaningful impact of anxiety disorder prevention programmes remains unknown.

Emotional Competence and Anxiety in Childhood and Adolescence: A Meta-Analytic Review

Anxiety is conceptualized as a state of negative emotional arousal that is accompanied by concern about future threat. The purpose of this meta-analytic review was to evaluate the evidence of associations between emotional competence and anxiety by examining how specific emotional competence domains (emotion recognition, emotion expression, emotion awareness, emotion understanding, acceptance of emotion, emotional self-efficacy, sympathetic/empathic responses to others' emotions, recognition of how emotion communication and self-presentation affect relationships, and emotion regulatory processes) relate to anxiety in childhood and adolescence. A total of 185 studies were included in a series of meta-analyses (N's ranged from 573 to 25,711). Results showed that anxious youth are less effective at expressing (r = -0.15) and understanding emotions (r = -0.20), less aware of (r = -0.28) and less accepting of their own emotions (r = -0.49), and report less emotional self-efficacy (r = -0.36). More anxious children use more support-seeking coping strategies (r = 0.07) and are more likely to use less adaptive coping strategies including avoidant coping (r = 0.18), externalizing (r = 0.18), and maladaptive cognitive coping (r = 0.34). Emotion acceptance and awareness, emotional self-efficacy, and maladaptive cognitive coping yielded the largest effect sizes. Some effects varied with children's age. The findings inform intervention and treatment programs of anxiety in youth and identify several areas for future research.

School-based cognitive behavioral interventions for anxious youth: study protocol for a randomized controlled trial

Background

Anxiety disorders are prevalent among adolescents and may have long-lasting negative consequences for the individual, the family and society. Cognitive behavioral therapy (CBT) is an effective treatment. However, many anxious youth do not seek treatment. Low-intensity CBT in schools may improve access to evidence-based services. We aim to investigate the efficacy of two CBT youth anxiety programs with different intensities (i.e., number and length of sessions), both group-based and administered as early interventions in a school setting. The objectives of the study are to examine the effects of school-based interventions for youth anxiety and to determine whether a less intensive intervention is non-inferior to a more intensive intervention.

Methods/design

The present study is a randomized controlled trial comparing two CBT interventions to a waitlist control group. A total of 18 schools participate and we aim to recruit 323 adolescents (12-16 years). Youth who score above a cutoff on an anxiety symptom scale will be included in the study. School nurses recruit participants and deliver the interventions, with mental health workers as co-therapists and/or supervisors. Primary outcomes are level of anxiety symptoms and anxiety-related functional impairments. Secondary outcomes are level of depressive symptoms, quality of life and general psychosocial functioning. Non-inferiority between the two active interventions will be declared if a difference of 1.4 or less is found on the anxiety symptom measure post-intervention and a difference of 0.8 on the interference scale. Effects will be analyzed by mixed effect models, applying an intention to treat procedure.

Discussion

The present study extends previous research by comparing two programs with different intensity. A brief intervention, if effective, could more easily be subject to large-scale implementation in school health services.

Trial registration

ClinicalTrials.gov, NCT02279251. Registered on 15 October 2014. Retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1831-9) contains supplementary material, which is available to authorized users.

Applying new evidence standards to youth cognitive behavioral therapies - A review

This review included 136 published randomized controlled trials (RCTs) of youth cognitive behavioral therapy (CBT) treatments. We aimed to test the premise that evidence-based youth treatments can be better differentiated from each other by applying more nuanced standards of evidence. Accordingly, we applied three standards to this article sample to determine how many treatments produced significant results: (a) on multiple target symptom measures, (b) at follow-up, and/or (c) against an active comparison group. We identified how many trials met standards individually and in combination. Although 87 of the 136 articles produced at least one significant treatment result at post-assessment, the subsets of "passing" articles were smaller and varied for any one of our three standards, with only 11 articles (8%) meeting all three standards simultaneously. Implications are discussed regarding the definition of "evidence-based," the need for multi-parameter filtering in treatment selection and clinical decision making, and future directions for research. We ultimately argue the value in assessing youth treatments for different types of evidence, which is better achieved through dynamic sets of standards, rather than a single approach to assessing general strength of evidence.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders

The present article uses meta-analysis to examine treatment components related to outcome within 35 randomized controlled trials (RCTs) for childhood anxiety disorders (CADs) and eight RCTs for childhood obsessive compulsive disorder (OCD). Examination of the RCTs of cognitive behavioral therapy (CBT) for CADs suggested that adding relaxation and delaying exposures until after the introduction of other anxiety management strategies does not increase the efficacy of exposure-based treatment. In addition, compared to the large effect size (ES) associated with exposure and response prevention (ERP) for OCD (k = 9, mean ES = 1.93), the effect size associated with CBT for CADs (k = 44, mean ES = 0.89) did not differentiate from attention placebo (k = 11, mean ES = 0.55), although it was more effective than waitlist control (k = 24, mean ES = 0.22). Instructively, ERP for OCD involved more exposure initiated earlier and less relaxation than CBT for CADs. In addition, RCTs of ERP were more likely to use clinician-administered measures as opposed to self-report and to be conducted in clinical versus recruited samples. These results suggest that dismantling studies using a gold-standard clinician-rated outcome measure to compare the value of adding anxiety management strategies to exposure will be necessary to increase the efficacy of CBT for CADs to levels achieved by ERP for OCD.

Practitioner Review: School-based interventions in child mental health

BACKGROUND

School-based interventions (SBIs) are well-established and effective treatments for improving child mental health. Specific school-based topics include prevention (Tier I-III) and interventions (e.g. cognitive-behavioural programmes and daily report cards).

METHODS

We performed a systematic literature search in five commonly used online databases (ERIC, MEDLINE, PsycARTICLES, PsycINFO and PSYNDEX) for English-language articles published between 1993 and 2015. Additional sources included reference lists of relevant articles and book chapters.

RESULTS

We identified a number of successful behavioural or cognitive-behavioural programmes yielding moderate to strong effects for a range of emotional and behavioural problems. The implementation of these programmes and the collaboration of the involved settings (school and home) and persons are important factors for their effectiveness under real-life conditions.

CONCLUSIONS

Effective SBIs are valuable tools for students with mental health problems if evidence-based cognitive-behavioural interventions are applied and rules of translational algorithms and implementation science are respected.

Study protocol of an RCT of EMOTION: An indicated intervention for children with symptoms of anxiety and depression

Background

High levels of anxiety and depression are common psychological symptoms among children and adolescents. These symptoms affect young people in multiple life domains and are possible precursors of long-term psychological distress. Despite relatively high prevalence, few children with emotional problems are referred for clinical treatment, indicating the need for systematic prevention. The primary aim of this study is to evaluate an indicated preventive intervention, EMOTION Coping Kids Managing Anxiety and Depression (EMOTION), to reduce high levels of anxiety and depressive symptoms.

Methods/Design

This is a clustered randomized controlled trial involving 36 schools, which are assigned to one of two conditions: (a) group cognitive behavioral intervention EMOTION or (b) treatment as usual (TAU). Assessments will be undertaken at pre-, mid - intervention, post-, and one year after intervention. The children (8–11 years old) complete self-report questionnaires. Parents and teachers report on children. The primary outcome will be changes in depressive and anxiety symptoms as measured by the Short Mood and Feelings Questionnaire (SMFQ) and Multidimensional Anxiety Scale for Children (MASC) respectively. Secondary outcomes will be changes in self-esteem, quality of life, and school and daily functioning. Observers will assess implementation quality with ratings of fidelity based on video recordings of group leaders leading the EMOTION group sessions.

Discussion

The present study is an important contribution to the field regarding working with children with symptoms of anxiety and depression. The results of this study will provide an indication whether or not the EMOTION program is an effective intervention for the prevention of later depression and/or anxiety in children. The study will also provide information about the EMOTION program’s effect on quality of life, self-esteem, and school functioning of the children participating in the study. Finally, the project will provide insight into implementation of an indicated intervention for school-aged children within Norwegian health, education, and mental health services.

Trial registration

Clinical Trials NCT02340637, Registered on June 12, 2014, last updated on January 15, 2015. Retrospectively registered.

School-Based Interventions for Anxious Children: Long-Term Follow-Up

This study examined the long-term outcomes of a nonclinical sample of anxious children (N = 61) who were randomized by school to 9 weeks of group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training, or no-treatment control. Parents and children completed measures of anxiety symptoms at baseline, posttreatment, and at 3-, 6-, 12-month, 2-, and 3-year posttreatment follow-ups. Piecewise longitudinal growth curve analyses were applied to the data. When the two CBT groups were combined and compared with control, the combined treatment group showed significantly greater reduction in children's anxiety severity based on the parent ratings in the first longitudinal phase. However, on the parent Clinician Severity Rating, gains were maintained to 3 years. Child report revealed no significant differences between groups on anxiety reduction. This study maintained a small no-treatment control group during the entire follow-up period. From parental perspective only, school-based group CBT appeared to be beneficial in decreasing severity of anxiety symptoms and maintaining gains over time.

Fitting anxious emotion-focused intervention into the ecology of schools: results from a test anxiety program evaluation

Emotion-focused prevention and intervention efforts in schools have been promoted as a significant developmental and public health priority. This paper reports the results of a longitudinal study testing central premises of a school-based prevention model aimed at promoting positive emotional development through targeting test anxiety. Test anxiety interventions may be a practical strategy for conducting emotion-focused prevention and intervention efforts because of a natural fit within the ecology of the school setting. At-risk youth (n = 1,048) from urban public schools were screened and 325 with elevated test anxiety were offered the intervention in one of two waves (immediate intervention vs. waitlist). The intervention was associated with decreases in test anxiety, anxiety disorder, and depression symptoms. Critically, results suggest high participant satisfaction and growth curve analysis of follow-up assessments (end of the year, the next school year, and a subsequent school year) demonstrated positive developmental trajectories consistent with predictions (e.g., initial change in test anxiety predicted change in other symptoms). Findings provide evidence for the ecological validity of targeting test anxiety in school-based, emotion-focused prevention efforts.

Predictors of treatment outcome in an effectiveness trial of cognitive behavioral therapy for children with anxiety disorders

A substantial number of children with anxiety disorders do not improve following cognitive behavioral therapy (CBT). Recent effectiveness studies have found poorer outcome for CBT programs than what is typically found in efficacy studies. The present study examined predictors of treatment outcome among 181 children (aged 8-15 years), with separation anxiety, social phobia, or generalized anxiety disorder, who participated in a randomized, controlled effectiveness trial of a 10-session CBT program in community clinics. Potential predictors included baseline demographic, child, and parent factors. Outcomes were as follows: a) remission from all inclusion anxiety disorders; b) remission from the primary anxiety disorder; and c) child- and parent-rated reduction of anxiety symptoms at post-treatment and at 1-year follow-up. The most consistent findings across outcome measures and informants were that child-rated anxiety symptoms, functional impairment, a primary diagnosis of social phobia or separation anxiety disorder, and parent internalizing symptoms predicted poorer outcome at post-treatment. Child-rated anxiety symptoms, lower family social class, lower pretreatment child motivation, and parent internalizing symptoms predicted poorer outcome at 1-year follow-up. These results suggest that anxious children with more severe problems, and children of parents with elevated internalizing symptom levels, may be in need of modified, additional, or alternative interventions to achieve a positive treatment outcome.

Enhancing the Capacity of School Nurses to Reduce Excessive Anxiety in Children: Development of the CALM Intervention

PROBLEM

Excessive anxiety is among the most common psychiatric problems facing youth. Because anxious youth tend to have somatic complaints, many seek help from the school nurse. Thus, school nurses are in an ideal position to provide early intervention. This study addresses this problem and describes the plans to develop and test a new intervention (Child Anxiety Learning Modules; CALM), delivered by school nurses, to reduce child anxiety and improve academic functioning.

METHODS

An iterative development process including consultation with an expert panel, two open trials, and a pilot randomized controlled study comparing CALM to usual care is proposed. Feedback will be solicited from all participants during each phase and data on outcome measures will be provided by children, parents, teachers, and independent evaluators.

FINDINGS

Data will be collected on intervention satisfaction and feasibility. Primary outcomes that include child anxiety symptoms, classroom behavior, and school performance (e.g., attendance, grades, standardized test scores) will be collected at pre- and post-interventions and at a 3-month follow-up evaluation.

CONCLUSIONS

Pediatric anxiety is a common problem that school nurses frequently encounter. Consequently, they are well positioned to play a key role in enhancing access to behavioral health interventions to reduce anxiety and may therefore make a significant positive public health impact.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

Integrating children with psychiatric disorders in the classroom: a systematic review

BACKGROUND

The school setting may be the optimal context for early screening of and intervention on child mental health problems, because of its large reach and intertwinement with various participants (child, teacher, parent, other community services). But this setting also exposes children to the risk of stigma, peer rejection and social exclusion. This systematic literature review investigates the efficacy of mental health interventions addressed to children and adolescents in school settings, and it evaluates which programs explicitly take into account social inclusion indicators.

METHOD

Only randomized controlled trials conducted on clinical populations of students and carried out in school settings were selected: 27 studies overall. Most studies applied group Cognitive Behavioural Therapy or Interpersonal Psychotherapy.

RESULTS

Findings were suggestive of the effectiveness of school-based intervention programs in reducing symptoms of most mental disorders. Some evidence was found about the idea that effective studies on clinical populations may promote the social inclusion of children with an ongoing mental disorder and avoid the risk of being highly stigmatized.

CONCLUSION

School programs are still needed that implement standardized models with verifiable and evidence-based practices involving the whole school community.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

A previous Cochrane review (James 2005) showed that cognitive behavioural therapy (CBT) was effective in treating childhood anxiety disorders; however, questions remain regarding (1) the relative efficacy of CBT versus non-CBT active treatments; (2) the relative efficacy of CBT versus medication and the combination of CBT and medication versus placebo; and (3) the long-term effects of CBT. 

OBJECTIVES

To examine (1) whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison with (a) wait-list controls; (b) active non-CBT treatments (i.e. psychological placebo, bibliotherapy and treatment as usual (TAU)); and (c) medication and the combination of medication and CBT versus placebo; and (2) the long-term effects of CBT.

SEARCH METHODS

Searches for this review included the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Depression, Anxiety and Neurosis Group Register, which consists of relevant randomised controlled trials from the bibliographic databases－The Cochrane Library (1970 to July 2012), EMBASE, (1970 to July 2012) MEDLINE (1970 to July 2012) and PsycINFO (1970 to July 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of CBT versus waiting list, active control conditions, TAU or medication were reviewed. All participants must have met the criteria of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) for an anxiety diagnosis, excluding simple phobia, obsessive-compulsive disorder, post-traumatic stress disorder and elective mutism.

DATA COLLECTION AND ANALYSIS

The methodological quality of included trials was assessed by three reviewers independently. For the dichotomous outcome of remission of anxiety diagnosis, the odds ratio (OR) with 95% confidence interval (CI) based on the random-effects model, with pooling of data via the inverse variance method of weighting, was used. Significance was set at P < 0.05. Continuous data on each child's anxiety symptoms were pooled using the standardised mean difference (SMD).

MAIN RESULTS

Forty-one studies consisting of 1806 participants were included in the analyses. The studies involved children and adolescents with anxiety of mild to moderate severity in university and community clinics and school settings. For the primary outcome of remission of any anxiety diagnosis for CBT versus waiting list controls, intention-to-treat (ITT) analyses with 26 studies and 1350 participants showed an OR of 7.85 (95% CI 5.31 to 11.60, Z = 10.26, P < 0.0001), but with evidence of moderate heterogeneity (P = 0.04, I² = 33%). The number needed to treat (NNT) was 6.0 (95% CI 7.5 to 4.6). No difference in outcome was noted between individual, group and family/parental formats. ITT analyses revealed that CBT was no more effective than non-CBT active control treatments (six studies, 426 participants) or TAU in reducing anxiety diagnoses (two studies, 88 participants). The few controlled follow-up studies (n = 4) indicate that treatment gains in the remission of anxiety diagnosis are not statistically significant.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or TAU or medication at follow-up, is limited and inconclusive.

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background

The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health.

Objectives

To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision.

Design

Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study.

Setting

Global (systematic reviews); England and Wales (mapping exercise and case study).

Participants (case study)

Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites.

Main outcome measures (meta-analysis)

A measure of CYP’s mental health symptomatology.

Data sources (literature reviews)

MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC).

Review methods

Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review.

Results

Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support.

Conclusions

Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes.

Future work

Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness.

Study registration

PROSPERO number (for the effectiveness review) CRD42012001981.

Funding

The NIHR Health Services and Delivery Research programme.

Selective Mutism in Early Childhood

Selective mutism (SM) is a relatively uncommon disorder in childhood, occurring in only 0.3 to 1.8 children per thousand. In early childhood, diagnosing SM can be particularly challenging, and the condition often goes unrecognized until the school years. Given the potential comorbidity of anxiety and communication deficits, treatment can be challenging and attendance in early childhood educational programs allows intervention in a contextually sensitive way that may also help address comorbidities and promote generalization. Thus, this case study of an African American preschool boy highlights the unique obstacles and opportunities of assessment and treatment in a preschool setting. Furthermore, we describe a three-step behavioral approach to addressing SM in collaboration with educators over a 3-month period. Substantive research indicates that early intervention with SM is associated with decreased likelihood of developing an anxiety-related disorder later in childhood; therefore, tailored assessment and intervention in early childhood within a community-based setting may be extremely useful.

A personalized and control systems engineering conceptual approach to target childhood anxiety in the contexts of cultural diversity

In the child and adolescent anxiety area, some progress has been made to develop evidence-based prevention protocols, but less is known about how to best target these problems in children and families of color. In general, data show differential program effects with some minority children benefiting significantly less. Our preliminary data, however, show promise and suggest cultural parameters to consider in the tailoring process beyond language and cultural symbols. It appears that a more focused approach to culture might help activate intervention components and its intended effects by focusing, for example, on the various facets of familismo when working with some Mexican parents. However, testing the effects and nuances of cultural adaption vis-à-vis a focused personalized approach is methodologically challenging. For this reason, we identify control systems engineering design methods and provide example scenarios relevant to our data and recent intervention work.

An explorative cost-effectiveness analysis of school-based screening for child anxiety using a decision analytic model

Anxiety in children is highly frequent and causes severe dysfunction. Various studies have used screening procedures to identify high-anxious children and offer them indicated prevention, but the cost-effectiveness of these screening procedures in combination with a preventive intervention has never been examined. This study compared four potential strategies in relation to the prevention of child anxiety: (1) a one-time school-based screening which offers a child-focused intervention, (2) the screening and offering of a parent-focused intervention, (3) the screening and differentially offering a child- or parent-focused intervention, depending on whether or not the parents are anxious themselves, and (4) or doing nothing. An economic evaluation from a societal perspective (i.e. including direct healthcare costs, direct non-healthcare costs, indirect costs, and out-of-pocket costs), using a decision-analytic model. The model was based on the real-world 2-year participation rates of screening and intervention, and real-world costs and effects of high- and median-anxious children (aged 8-12) from regular primary schools. Incremental cost-effectiveness ratios were calculated, and several secondary and one-way sensitivity analyses were performed. The strategy of doing nothing and the strategy of screening and differentially offering the child- or parent-focused intervention, depending on parental anxiety levels were both worthwhile, with the latter strategy costing relatively little extra money compared to doing nothing. In conclusion, some evidence for the cost-effectiveness of screening and intervening was found. Screening and offering a parent-focused intervention to children of anxious parents, and a child-focused intervention to children of non-anxious parents, were found to be the most cost-effective approach.

School-based anxiety treatments for children and adolescents

Anxiety disorders are the most common class of psychopathology among youth, yet many of these youngsters do not receive treatment. This is particularly concerning given the chronic course of anxiety disorders, which often lead to mood disorders, substance abuse, and serious impairment. Schools are an optimal venue for identifying anxious students and delivering mental health treatment given access to youth and ability to overcome various barriers to treatment. This article reviews four school-based treatments for anxiety disorders that have been evaluated in controlled trials. Discussion centers on feasibility, challenges to school-based implementation, and future research directions for this critical area.