Principal Investigator: Mark Dadds & Susan Spence
Level of Intervention: Indicated
Target Population: Children and adolescents age 7 to 14 years old with elevated and clinical levels of anxiety symptoms and no disruptive behvaior problems.
References: Dadds, Holland, Laurens, Mullins, Barrett, & Spence, (1999); Dadds, Spence, Holland, Barrett, & Laurens (1997).
Theory (Risk & Protective Factors Targeted):
Anxiety is one of the most common forms of psychological distress reported by children & adolescents. Anxiety disorders are stable if untreated, and associated with other psychological problems. Children exhibiting early signs of anxious behavior are considered more at risk for anxiety disorders. Other risk factors include inhibited temperament, exposure to traumatic and negative life events, and having anxious, overprotective parents. Psychosocial interventions have been an effective form of treatment for children diagnosed with anxiety disorders.
Description of Intervention:
This child component consisted of a cognitive-behavioral, school-based, program that taught youth how to cope with anxiety. Group sessions (1-2 hours long) were conducted over a period of 10 weeks. The program is based on the Coping Koala Prevention Manual (Barrett, Dadds, & Holland, 1994), an Australian modification of Kendalls (1990, 1994) Coping Cat anxiety program for children. The strategies presented in the program are based on Kendalls FEAR plan which teaches children how to develop a plan of graduated exposure to fearful stimuli using physiological, cognitive, and behavioral coping strategies. Clinical psychologists led groups with graduate student co-leaders.
Parents participated in three sessions designed to introduce child management strategies, provide them with information on what their children were learning in the program, and teach them how to use similar strategies to manage their own anxiety.
Subjects were recruited from a pool of all 3rd through 7th grades from 8 primary schools (N=1,786) in Brisbane, Australia. The schools represented three SES levels. Students were screened on four levels. First, all children completed the Revised Child Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1979). Next, teachers nominated up to three children from their class who exhibited elevated anxiety symptoms and three children with elevated disruptive behavior problems. From the list of children who were nominated as anxious by teacher reports or who reported high levels of anxiety on the RCMAS, teachers were asked to identify non-English speaking children with learning problems, children with developmental delay, or those who they clearly felt were well-adjusted and without an anxiety problem. These children were excluded from the subject pool. Finally, the Anxiety Disorders Interview Schedule for Children Parent Version (ADIS-P; Silverman & Nelles, 1988), a diagnostic interview was conducted with parents (N=181). Children eligible for this final screen scored 20 or above on the anxiety scale of the RCMAS and were nominated by their teacher as anxious. They were not on their teachers list of disruptive students and they did not meet any of the reasons for exclusion listed above.
The final sample consisted of 128 students who ranged from 9 to 14 years old. The majority of the sample was White and ranged from working to middle class. Children who met criteria for a DSM-IV anxiety disorder with a severity rating of 5 or less (on an 8-point scale), or who did not meet criteria but had features of an anxiety disorder or met criteria for a nonspecific sensitivity, were allowed to participated. Students were excluded from participation if the diagnostic interview revealed an externalizing disorder.
Schools were matched for size, demographics, and SES and then randomly assigned to condition. Subjects were assigned to either an intervention or monitoring condition depending on the school they attended.
There were no significant differences between or within the intervention and comparison groups or between the schools on any demographic or diagnostic variables. Schools were the unit of assignment so the degrees of freedom derived from the number of schools were used in tests comparing the treatment and control groups.
The results are somewhat difficult to interpret because subjects who qualified as having a disorder prior to the intervention and those who were symptomatic but non-disordered were mixed together in the groups. When the symptomatic but non-disordered group was compared to controls there were no significant differences found at post-intervention.
Follow-up (6 month):
Significant differences were found in anxiety diagnoses between the intervention and control groups. Only 16% of the children in the treatment group (without a diagnosis at the pre-assessment) had a diagnosable disorder at follow-up compared to 54% of the children in the control group (p<.05).
Follow-up (12 month & 24 month)
Results of an extended follow-up at 12 and 24 months have recently been reported (Dadds, Holland, Laurens, Mullins, Barrett, & Spence, 1999). No effects were found at 12 months. At 24 months significant differences were found for parent reports of avoidance (p<.005) and overall clinician impressions (p<.001) derived from parent telephone interviews. A significant diagnostic effect indicated that 20% of the intervention children (this group included both those with and without diagnoses at the pre-assessment) still met criteria for anxiety disorders as compared to 39% in the control group.
Strengths & Limitations:
The Queensland Early Intervention and Prevention of Anxiety Project utilized a cognitive-behavioral program to teach children exhibiting clinical and sub-clinical levels of anxiety, adaptive coping strategies for managing their distress. The program also targeted the families to support their childs developing skills and use similar methods to manage of their own anxiety. Although there were no treatment effects immediately after the intervention concluded, 6 months later the intervention children were less likely to develop an anxiety disorder. These results are promising, particularly given the design of the study (randomized trial) and the use of diagnostic classifications as outcome measures. Effects appeared to fade at 12 months, but again showed impact at 24 months. Unfortunately, no student self-report data was available at the 12 and 24-month follow-up. The findings are difficult to generalize, though, given that the sample was primarily Caucasians in Australia.
Attempts were made to ensure program fidelity but the details provided on this aspect of the evaluation were significantly less than those provided for subject recruitment processes and characteristics. The child component was based on an intervention manual. Although the parent program was not a published program, attempts were made to standardize the presentations by using a set of visual slides with written scripts. Training of therapists took place in a one-day workshop where they were introduced to the program and given an opportunity to rehearse the intervention. The group leaders provided on-going supervision of the therapists in order to ensure treatment integrity. There has been no independent replication of the program.