dadds spence 1997 prevention and early intervention for anxiety disorders jconsulting clinical...

8/21/2019 Dadds Spence 1997 Prevention and early intervention for anxiety disorders JConsulting Clinical Psychology

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Journal ofConsultingandClinical Psychology1997, Vol.65, No. 4,627-635Copyright 1997 by the American Psychological Association, Inc.0022-006X/97/$3.00

PreventionandEarly InterventionforAnxietyDisorders:AControlledTrial

MarkR.DaddsGriffithUniversity SusanH.SpenceUniversity of Queensland

Denise E. Holland, Paula M. Barrett, and Kristin R. LaurensGriffithUniversity

The Queensland Early Intervention and Prevention ofAnxietyProject evaluated the effectiveness ofacognitive-behavioraland family-based group intervention for preventing the onset and developmentof anxiety problems in children. A total of 1,786 7- to 14-year-olds were screened for anxietyproblems using teacher nominationsand children's self-report. After recruitment anddiagnosticinterviews, 128children were selectedandassigned to a10-week school-basedchild-andparent-focused psychosocial intervention or to a monitoring group. Both groups showed improvementsimmediatelypostintervention.At 6 months follow-up, the improvement maintained in the interventiongrouponly, reducing the rate of existing anxietydisorderand preventing theonsetof new anxietydisorders.Overall,theresults showed that anxietyproblemsanddisordersidentified using childandteacherreportscan besuccessfullytargetedthroughanearly intervention school-based program.

There is growing evidence to suggest that anxiety disordersinchildhoodand adolescence aresignificantand warrant moreattention fromresearchers and clinicians. Anxiety disorders arethemost common form ofpsychological distress reported bychildren andadolescents(Garralda& Bailey, 1986; Kashani,Orvaschel, Rosenberg,&Reid, 1989; Viken,1985),tendto bestable through childhoodandadolescence unlesstreated(Cant-well &Baker,1989), and areassociatedwith a range of psy-chosocial impairments(Mattison,1992).Thus, although child-hoodcan beexpectedtoinclude transientfearsandanxieties,asignificantproportion of children will develop anxiety problemspredictive of generalized and long-term impairment if leftuntreated.

Recently,controlled trials have demonstrated theeffectivenessofpsychosocial interventionsforchildandadolescentanxietydisorders.Kendall(1994)evaluated the effectiveness of a cogni-tive-behavioral therapy(CBT)program for 9- to 13-year-oldchildrenwithoveranxious, separation, andsocial anxietydisor-ders. Compared with a wait-list control, the treated childrenshowed clinically significant gains that were maintained over

MarkR.Dadds, DeniseE.Holland,Paula M. Barrett, andKristinR.Laurens,School ofApplied Psychology, FacultyofHealth andBehav-ioural Sciences, Griffith University, Nathan, Queensland, Australia; Su-san H. Spence, Department of Psychology, University of Queensland,St.Lucia, Queensland, Australia.

Thisresearchwas supported by grants from the National Health andMedical Research CouncilofAustraliaand theQueensland Health Pro-motion Council. Thanksto Catholic EducationofQueensland fortheirhelp.

Correspondence concerning this article shouldbeaddressedtoMarkR.Dadds,School of Applied Psychology, Faculty of Health and Behav-iouralSciences,Griffith University, Nathan, Queensland4111Australia.Electronicmail may be sent via Internet to [email protected].

anaverage follow-up period of 3.5 years (Kendall &Southam-Gerow, 1996).A second outcome study has shown similar ef-fects (Kendall, Flannery-Schroeder, et al., 1997). Barrett,Dadds,andRapee(1996)compareda CBTintervention basedonKendall's(1990)program to an intervention that includedthe CBT intervention plus a family intervention, for a mixedgroupof 7- to14-year-olds with overanxiety, separation anxiety,andsocial phobia disorders. Both interventions achieved a no-diagnosisstatus (that is, no existing diagnosis) in over 60% ofchildrenatposttreatment compared withless than30% ofchil-dren on thewait-list.At the 12-monthfollow-up, no-diagnosisrates were70% and 95% for the CBT and CBT +familyinter-ventiongroups, respectively.

Theseclinical trials indicate that anxiety disorders in latechildhood and early adolescence can beeffectivelytreated. How-ever,tertiary treatmentsmay not be themosteffectiveorefficientmethod formanaging child psychopathologyandbehaviordisor-ders (Kazdin, 1987). Early intervention andprevention pro-grams aimedatlarger cohortsofchildrenincommunity settingshave thepotential to be more cost-effective in reducing theoverall incidenceofchildhood disorders andtheir cost to thecommunity. Althoughnosuch workwithcommunity cohortsofanxiouschildrenhasbeen reported,anumberofauthors (King,Hamilton,&Murphy,1983; Spence, 1994) have discussed thepotentialofsuch programsforchildrenatriskfor thedevelop-ment ofanxiety disorders.

Acritical issuein thedesign ofpreventive programsis thechoiceofcriteriaforselectionofat-risk children.To beexclu-sively preventive in focus would exclude children alreadyshowinganxiety problems from thebenefits ofearly interven-tion. On theother hand, previous researchhasdocumentedeffec-tivetreatmentsforchildrenwithsevere disturbance (Barrettetal.,1996; Kendall,1994).Thus, the Queensland EarlyInterven-tion and Prevention of Anxiety Project (QEIPAP; Dadds &

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628 DADDS, SPENCE, HOLLAND, BARRETT, AND LAURENSSpence, 1994) combinedapreventivewithanearly-interventionapproachtomanagingthedevelopmentofanxiety disordersinyoungpeople.The aim was tointerveneforchildren,fromthosewho were disorder-freebutshowed mild anxious features tothosewho metcriteriafor ananxiety disorder butwerein theless severe range. These children are henceforth referred to asatrisk.

Three toolsarerequiredtomounteffectivepreventionorearlyinterventionprograms: (a) an identification strategy (screen)thatreliablyidentifieschildrenatrisk;(b)anaccess point wheresuchchildrencan beidentified; and (c) anintervention proce-durethatcan beimplementedwithoutmajorcostto theclienteleor themental health system.For anxietydisorders, these require-mentsare partly inplace. Child andparental report measuresareavailable thatoffermoderate accuracyin identifyingchildrenwith,or atrisk for, anxiety problems(King,Hamilton,&Ollen-dick, 1988; Laurent,Hadler, & Stark, 1994; Perrin & Last,1992), and the Anxiety Disorder Interview Schedule(ADIS;Silverman &Nelles, 1988) reliablyidentifieschildrenwithspe-cificanxietydisordersaslistedin theDiagnosticand StatisticalManual of Mental Disorders (3rd ed., revised; DSM-HI-R;American Psychiatric Association, 1987; Rapee, Barrett,Dadds,&Evans,1994).Although existing measuresmay be oflimited validityin their ability to discriminate anxiety problemsfromother behavior problemsinchildren (Perrin&Last,1992),the use of multiple informants andmeasures can be used toreliablyidentify childrenatriskfor anxietyproblems.

School systems can provide access points to the cohorts ofchildreninappropriateagerangesfor theidentificationofchil-dren atrisk,andintervention programsareavailable that havebeenshowntoreduce anxiety problems when implementedwithgroupsofchildrenwithestablished anxiety disorders (Barrett,Dadds, Rapee,&Ryan,1993).This program used reportsfromteachersand childrenaccessedin theschoolsystemto identifyat-risk children and used acombined social learning/familyapproachtointervention withinarandomized design.Wewereinterestedindesigningaprogram that couldbeeasilyandeffec-tivelymountedinmostschoolsettingsandthatwouldmeettheneedsof themajority ofchildrenat risk for anxiety problems(i.e.,wascomprehensive). Mostanxietyproblemsin childrenemergeinlate childhood,and atleastthislevelofmaturityisneededforchildrentobenefit fromcognitively focused psycho-therapies. Thus,theprimary schoolagegroupof 7- to 14-year-oldswasselectedas ourtarget population.

Theoverallaim of thepresent studywas toevaluateanearlyintervention and prevention program. Thespecificaims were toexaminetheremediatingeffectsof theinterventiononchildren'sfunctioning atpostintervention and at 6-month follow-up,incomparison with a no-intervention monitoring group. It washypothesized that the intervention wouldbe associated withlower ratesofanxiety problems anddisorders, comparedwithnonintervention, postintervention, and 6-month follow-up, asmeasuredbydiagnostic interviewswithparentsandstandard-ized self-report forms.

MethodParticipants

Initial participants were a cohort of 1,786 children (1,056 girls[59.1%], 730boys [40.9%]),representingallchildren between7 and

14years of agefromGrades 3 to 7 of eight preselected primary schoolsinthemetropolitan areaofBrisbane,Australia,anurban cityofapproxi-mately 1millionpeople.Theschools were selectedtorepresenteachofthree levelsofsocioeconomicstatuson thecriteria ofaverage incomeandoccupational status of the population of the school catchment area.The percentage of families in each of the eight catchmentareasearningless than$16,000per year ranged from4% to 24%, and the percentageofthose earning above$60,000ranged from7% to 30%. The majorityofchildren attending these schools (andliving in Brisbane in general)were White, Anglo-Saxon, Catholic or Protestant Christian, and workingtomiddleclass.Substantial ethnic populationsofChinese, Vietnamese,Latin American, Greek, and Italian also existed in various numbers(5% to 27%fromnon-English-speaking backgrounds) across catchment

Procedure:ScreeningandSelectionA screening procedure incoiporating both children's and teachers'

reports was used toidentifychildren at risk for anxietydisorders.ScreeningI. Allchildren(N =1,786)completed theRevised Chil-

dren'sManifest Anxiety Scale (RCMAS; Reynolds&Richmond,1979).This checklist measures physiological symptoms, worry, and inatten-tivenessassociatedwith anxiety problems in children, and produces anoverall anxietyscoreand a lie scale.Our previous researchandotherstudies(e.g.,Perrin&Last, 1992) have shown thatnosingle self-reportmeasure of anxiety in children can reliably discriminate anxious childrenfromchildren with other behavior problems. Thus, we expected Screen-ing 1 to identify children in each school with anxiety problems butalso a small number of children withattention deficit andoppositionalproblems without anxiety problems (Perrin Last, 1992).Given thatthiswas the first trial of implementing an anxiety treatment in schoolsettings,we were concerned that the inclusion of children withcomorbiddisruptive behaviorproblemswould compromise the specificity of ourresultsand pose difficulties for therapists working withgroupsof chil-dren. Another screeningphase wasused, therefore,toexclude childrenwithdisruptive behavior problemsfrom thesample.

Screening2. Teachers nominatedup to 3childrenfromeach classwhodisplayed the most anxiety(i.e.,were shy, nervous, afraid, inhibited;this was an inclusioncriterion) and up to 3 who displayed the mostdisruptive behavior (i.e., were impulsive, aggressive, hyperactive, non-compliant;this was anexclusioncriterion). Previous research has sup-ported the ability of teachers to identify children at risk for anxietyproblems (Strauss, Frame,&Forehand, 1987) anddisruptive behaviorproblems (Kazdin,1987).

Screening3. Preliminary scanning of the children recruited throughthefirst twoscreensrevealedthat there were childrenwho had scoredhighlyon theRCMASbutwere inappropriateforinclusionin theinter-vention; thatis,theyhaddevelopmental problemsordisabilities,orcamefromhomes where English was not spoken. It was additionally apparentthatconvergence betweenteachers'and children's reports was unexpect-edlylow, suggestingthepossibility that someof therecruited childrenwere not anxious, but rather, hadcompletedthe RCMAS invalidly(i.e.,answered yes to all thequestions).Tocorrectforuieseconcerns,wesubmitted the lists of children who had been selected for the project,througheither RCMASscoreorteacher nomination,backtoclass teach-ers and asked them to identify any children on the list who (a) didnotspeak Englishin thehome, (b) hadsubstantial learning problems,disability, or developmental delay, or (c) clearly had no anxiety problems(i.e.,teacherswereconfidentthatthechildwaswell adjusted). Childrenwho wereselected for the final sample ready for parental interviewsthusmet the followingcriteria: They (a) scored 20 or above on theAnxiety scale of the RCMAS or (b) were included in theteacher'slistofanxious children, and (c) were not included in the teacher's list ofdisruptive children,and (d) werenot excluded by teachers on any oftheaforementioned grounds.


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PREVENTION OF ANXIETY DISORDERS 629

Screening4. Parents of children includedaftermeeting these criteriawere telephoned and briefly interviewed with the aim of arranging aface-to-face diagnostic interview(schoolor home). The telephone callsand interviews were conductedbyclinicians (postgraduateclinicalpsy-chologystudentsandclinicalpsychologists)who hadreceived 10 hroftrainingin thespecific protocol skills forapproachingandinterviewingfamilies. At the face-to-face interview, we asked parents to providedemographic data and tocompletethe Child BehaviorChecklist(CBCL;Achenbach & Edelbrock,1983),which was used as a treatment outcomemeasure and not for screening, and we administered the Anxiety Disor-ders Interview Schedule for ChildrenParent Version(ADIS-P;Sil-verman & Nelles, 1988) to produce a diagnostic formulation for eachchildinaccordance withthefourtheditionof theDSM(DSM-IV; Ameri-canPsychiatric Association, 1994).TheADIS-P assessed internalizingdisorders (separation anxiety [SAD], social phobia, specific phobias,generalizedanxiety[GAD],panicdisorderwithorwithoutagoraphobia,obsessive and compulsive behaviors, posttraumaticstress,sleepterror,-dysthymia, and major depression), externalizing disorders (attentiondeficit/hyperactivity,oppositional defiant, andconduct problems), andfunctionalenuresis,substance abuse, andschizophrenia.Children exhib-iting primarily externalizing behaviors were considered unsuitable forinclusionin the project and were excluded. No parent reported substanceabuse or schizophrenia.

Clinicians rated the severity of children's disordered behavior and theextent of interference caused by those behaviors on an 8-point ratingscale:0 = absent(no interference), 2 = mild(slightly disturbing/notreally disabling),4 = moderate(definitely disturbing/disabling), 6=marked(markedly disturbing/disabling), 8=severe(very severely dis-turbing/disabling).Aratingon thescalewasgivenforeachdiagnosticcategory for which parentsreportedtheir child showing problems. Chil-dren who met criteria for aDSM-IV anxiety disorder received a severityrating of 3 or more. Children who met one or more but not all ofthecriteria for aDSM-IV anxiety disorder were classified ashaving''features''of thedisorderandreceivedaratingof 1 or 2 on the scale.Several children whom parents reported as shy-sensitiveyet did notshow behaviorsspecificto an anxiety diagnosis wereconsideredto havea 'nonspecificsensitivity''andreceivedaratingof 1 on the scale. Thosechildren who either (a) met criteria for aDSM-IV anxietydisorderwitha severity rating of 5 or less, or (b) did not meet criteria but hadfeaturesof an anxietydisorderor a nonspecific sensitivity, wereofferedparticipationin thestudy.Anychildwithananxietydisorderof aclinicalseverityratingof 6 ormorewas referred forindividual treatmentandnotincluded.

Finalselectionandallocation. At theconclusionof theinterview,parents and their child were given feedback about theassessmentThosechildren who fell within theat-risk selection criteria were invited toparticipate in the early intervention and prevention study proper. Childrenselected were allocated to the intervention or monitoring condition onthebasisofschool. Schoolsmatched for size,sociodemographics,andsocioeconomicswere randomlyallocatedtocondition.

Intervention andcomparisongroups. InterventionwasbasedonTheCopingKoala: PreventionManual(Barrett, Dadds,&Holland,1994),which isidentical to TheCoping Koala: TreatmentManual (Barrett,Dadds, & Rapee,1991),an Australian modification ofKendall's(1990)CopingCatanxiety programforchildren, except thatit ispresentedingroupformatin 10sessions.TheCoping Koala treatment manualanditsoriginalsourcehave beendescribedindetailelsewhere (Barrettetal.,1996; Kendall,1994;Kendall&Treadwell,1996).The Coping Koalaprevention manual is a CBT program that teaches children strategies forcoping with anxiety within a group format. These strategies centeredonKendall's FEAR Plan, in which each child develops and implementstheirownplanforgraduated exposuretofear stimuli using physiological,cognitive, and behavioralcoping strategies:F, for feeling good by learn-ingtorelax;E, forexpecting good thingstohappen through positive

self-talk;A, foractions totakeinfacingup to fearstimuli;and R, forrewarding oneself for efforts to overcomefearor worry.Groupprocessesare used to help children learn positive strategiesfromeach other andreinforce individualefforts and change. The program was conductedover 10 weekly, 1- to 2-hr sessions at each intervention school. Groupsizes ranged from5 to 12 children. More specificdescriptions of theinterventionscan be foundin theKendallandBarrett references citedabove.

Leaders of the groups were clinical psychologists trained in deliveringtheprogramandwere assistedby one or twopostgraduate studentsascotherapists. Initial therapist trainingwasconductedas a1-day workshopin whichdeliveryof theintervention sessionswasrehearsed anddis-cussed.Therapists met weekly with program leaders over the 10 weeksto review treatment integrity and discuss any intervention problems orissues.Supervisors were required to take written records of any depar-tures from theprescribedtreatment protocol. Nosignificant departuresfrom theprescribed protocol were noted. Furthermore,thesupervisingtherapistshadpreviouslyparticipatedincontrolledtrialsinwhich treat-mentintegrity measures were taken,andthey were shownto beconsis-tent in their delivery of the program (i.e., Barrett etal.,19%; Cobham &Dadds, 1995).

Parentalsessionswere conducted at the intervention schools in Weeks3, 6, and 9. Session 1introduced parents tochild management skills(reinforcement skills, planned ignoring, giving and backing upclearinstructions)and how to use these skills to manage their child's anxiety.Session 2 explained what the children were learning in the Coping KoalaPrevention Programand howparents could model andencourage theuseof strategies learned. Session 3 showed parents how they could usethesame strategiesthat is,Kendall's FEARplantomanagethen-ownanxiety.Presenterswereasubsetof theclinical psychologistswhopresented the child intervention. The presentations were standardizedthrough a setformatofvisual slideswithaccompanying writtenscriptstoensuretheintegrityofthis partof theintervention.

The comparison groupsreceivedno intervention but were told thatthey would be contacted formonitoring in 12weeks and then at 6-monthintervalsfor 2years.

Follow-up assessments. After the intervention,andagainafter ap-proximatelya 6-month interval, parents completed the CBCL, and chil-drencompleted the RCMAS. Clinicians who had not been informed ofintervention status contacted parentsbytelephone andadministered ashortened version of theADIS-Pdiagnostic interview thatassessedSAD,social and simple phobias, GAD. and agoraphobia without panic disor-der.As pan of this telephone interview, parents rated the child on sixdimensions of change (overall functioning, overall anxiety, avoidantbehaviors, change offamily disruption bychild'sbehavior, changeofparental perception of ownability todeal withchild's behavior,andchangeofchild'sabilitytodealwithpreviously feared situations),andatthe end of theinterviewtheclinician ratedthechildon onedimensionofchange(clinicalglobal impression; Barrettetal., 1996).Anychildwhomet a diagnosis rated at aclinicalseverity rating of 6 or more orwhoseparents requested individual helpfortheir child's anxiety prob-lems wasreferred for individual treatment and excluded from furtherfollow-upassessment.

Diagnosticreliability. Weconducted reliability checkson 27% ofallface-to-face initial diagnostic interviewsby audiotaping theinitialinterview andhavingan independent diagnosticformulation made onthebasisof thetaperecording byanother clinicianwho had notbeeninformedof theprimaryinterviewer1sformulation. Accuracyof interraterreliability wascalculatedfordiagnoses categorizedaseithernodiagno-sis, anxiety disorder, or other diagnosis. This yielded kappas of .88and.79 for primary diagnosis and secondary diagnosis(i.e.,a seconddiagnosisthatwasless severe thantheprimary diagnosis), respectively,andcorrelations ofr =.89 and .92 for the two ratings of severity ofprimaryand secondary diagnoses, respectively. Reliability checks were


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630 DADDS, SPENCE, HOLLAND, BARRETT, AND LAURENSalso conducted on 18% of telephone interviews using two clinicians,one who conducted theinterview andmadeadiagnostic formulationandone wholistenedonanothertelephone extensionand made aninde-pendentdiagnosticformulation. Thekappasfor primary andsecondarydiagnoseswere 1.00 and.62,respectively, and correlations between theprimaryand secondaryseverityratingswerer =.96 and.94,respectively.Thesedata indicateadequatereliabilitylevels consistentwithour previ-ous studies of interrater reliability usingthe AD1S-P(Rapee et al.,1994).

ResultsOne hundred sixty children(9.0%)were identified by teach-

ers as having conductproblemsand were, thus, excluded. Thegroup did notdiffer significantly in agefromthenonaggressivepopulation. All of the children nominated as having conductproblems were excluded from furtherdata analyses.

From the remaining 1,626 children, 157 (9.7%) were identi-fiedby teachers as having anxiety problems. Ofthese,61.1%were female,closelycorresponding to theproportion expectedgiventhe overall proportion of girls in the population screened(59.1%).The age ofthis groupdid not differ fromthatof thesample of students not identified by teachers as anxious. Aseparate group of 171 children (10.5%) scored 20 or above ontheRCMAS.Theproportionof girls in this group(74.9%)wassignificantly higher than both the proportion recruited throughteacher nominations,X2(l , ff - 1) =7.10,p


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PREVENTION OFANXIETY DISORDERS 631

Table1Numbers andPercentagesof Children WithPrimaryDSM-IV DiagnosesandDiagnostic FeaturesbyRecruitmentMethod

Teacher report(n=

DiagnosisGeneralizedanxietySeparationanxietySimple phobiaSocialphobiaNonspecific sensitivityTotal:Anyanxiety problemDepressionOppositionaldefiantdisorderAttention deficitdisorderOtherTotal: Other diagnoses

Fulln92

15240

5011327

disorder%

10.12.2

16.927.00.0

56.21.11. 13.42.27.8

89 )

Features

n31665

2100112

%3.41.16.76.75.6

23.50.00.01.11.12.2

Child report(n =Fulldisorder

n121

1790

391441

10Teacher report

AnyDSM-IV diagnosisNodiagnosis, having featuresNodiagnosis,no features

57239

64.025.810.1

%16.71.4

23.612.50.0

54.21.45.65.61.4

14.0

72)Features

n50522

1400000

%6.90.06.92.82.8

19.40.00.00.00.00.0

Both (n =Fulldisorder

n42320

1101102

Child report49149

68.219.412.4

%20.010.015.010.00.0

55.00.05.05.00.0

10.0

Both136

20)Features

n2 10.00 0.01 5.02 10.01 5.06 30.00 0.00 0.00 0.00 0.00 0.0

65.030.05.0

Note. Mean numberof diagnoses is asfollows:Forteacherreport,M =0.96, SD=0.95;forchildreport,M =0.83, SD =0.84;forboth reports,M= 1.30, SD =1.38. DSM-IV - DiagnosticandStatisticalManual ofMental Disorders(4th ed.).

presented in all of theanxietydisorders (GAD, 77.1%; SAD,100%; simple phobia, 83.3%) except socialphobia, inwhichtheir proportion (57.8%) correspondedtothatof thelarger sam-ple (59.1%).

Intervention Participation and EffectsTable 2shows demographic anddiagnostic comparisonsof

the 128 children participating in the intervention trial.Therewerenonsignificant differences between thegroupson any ofthese variables. By the 6-month follow-up, 5 children had with-drawnfromparticipationin theprogram: 3children from themonitoring groupand 2childrenfrom theintervention group.At 6-month follow-up, 4childrenfrom themonitoring groupreceived a clinical severity rating above 6withassociated paren-talrequestsfor individualclinicalhelp. Dataforthese childrenwere includedin the6-monthfollow-upanalyses,and thechil-dren were referred forindividual therapy.No such cases oc-curred in theintervention group.

Data were keptonattendance rates atintervention sessionsfor childrenandparents in theintervention group. For the 10child intervention sessions, attendance was high:M =8.1, SD= 2.4,Mdn =9,mode = 10. For the three parent sessions,attendancebymotherswas asfollows:M =1.7,SD=1.1,Mdn= 2, Mode = 3; for fathers:M =0.63, SD = 1.0,Mdn = 0,Mode= 0.

Statistical comparisons between interventionandmonitoringgroupscan beconducted using degreesoffreedom derivedfromthe number of children (ns = 61 and 67, respectively) or thenumberofschools(ns = 4 and 4,respectively)ineach condi-tion.The latter was deemed more appropriatebecauseschools,

rather than children, weretheunitof ourrandom assignment.Differencesbetween groups were testedbothwaysandresultsweresubstantially similar. Also, there werenonsignificant differ-ences between schoolsondemographicordiagnostic variableseither between or within groups. Given that basing thestatisticson thenumberofchildrenineach group gave extra informationofvariance within groups,wehave thus reported statistics usingchildren ratherthanschools as thebasicdata unit.

Figure 1(top panel) shows comparisons of thediagnosticstatus ofchildren in theintervention versus monitoring groupsatpretreatment,posttreatment,and6-monthfollow-up.Atpre-treatment, approximately 75% of children interviewed met crite-ria for a DSM-IV diagnosis, with nonsignificant differencesacross groups, ;c2(l, A f = 1) = 1.75, ns. Thepercentage ofchildren meeting diagnosis at postintervention decreased forboth groups. Although the decrease wasvisibly larger in theintervention group,nostatistical differenceswerefoundbetweengroups,x2(l ,N = 1) = 2.83,ns.At the 6-month follow-up,theintervention group continuedtoshow improvement, whereasrecidivismwasevidentin themonitoring group.Differences inrates ofdiagnosis was significant at this 6-month follow-up,X2(l ,N= 1) = 10.67,p


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632 D A D D S , SPENCE, HOLLAND, BARRETT, AND L A U R E N STable 2Demographic an dDiagnostic Status ofChildrenin theIntervention and Monitoring roups

Demographic and statusMean of A x i s 1 severityMean no. ofdiagnosesMean age ofmother (in years)Maternal education*Mean age of father (inyears)PaternaleducationA ge ofchildNo. of siblings female two-parent families

Children with:A ny anxietydiagnosisG A DSA DSimple phobiaSocial phobiaOther diagnosisA nxiety featuresRecruitment methodTeacherSelf-reportBoth

Intervention(n=61 )M SD3.2 1.51.2 l.l39.1 4.71.3 0.742.3 6.11.4 0.79.5 1.62.3 1.373.869.4

68.914.84.916.429.53.331.145.939.314.8

Monitoring(n = 67)M SD3.3 1.21.1 0.838.3 5.21.5 0.740.5 5.11.5 0.69.3 1.62.3 1.471.681.8

79.120.93.029.922.43.020.956.732.810.4

Note, G A D = generalizedanxietydisorder;SA D = separation anxietydisorder. Educationratedon a 3-pointscaleon which 1 = less than secondaryschool, 2 = completed secondary school, and 3 = university.

mentwas evident in theinterventiongroup(= 41), but somerelapsewasevidentin themonitoring group(n = 52), xz O >N=1) 5.79,p


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PREVENTION OF ANXIETY DISORDERS 633

Table3RatingsofChangein Adjustment for Children and TheirFamiliesin theInterventionandMonitoringGroupsPoslinterventionand at 6-Month Follow-Up

Clinician'srating

TimeandgroupPostintervention

MonitoringIntervention

6-Month follow-upMonitoringIntervention

M

3.524.234.134.75

SD

0.931.170.991.15

OverallfunctioningM

3.624.124.334.61

SD

0.920.961.101.13

Overallanxiety

M

3.594.034.024.46

SD

0.891.031.161.19

AvoidanceM

3.323.954.064.49

SD

0.751.161.00.99

Familydisruption

M

3.203.623.053.37

SD

0.640.900.951.03

Parent'sability

M

3.414.023.553.80

SD

0.840.971.141.06

Child'sability

M

3.684.274.034.41

SD

0.791.091.011.05

Internalizing scales of theCBCLand the RCMAS, and stabilityon theCBCL Externalizing scale. Nonsignificant differencesbetween groups werefoundonthese measures. Further analysesof CBCL Internalizing subscales (anxiety/depression, socialwithdrawal) again found no group differences. It was notedearlier that childrenwhowere recruitedbyteachershadsignifi-cantly higher Lie scale scores than the other groups only atpretreatment.At posttreatment and 6-month follow-up, this wasnolonger the case. However, there was a relationship betweenliescoresand diagnostic status at posttreatment in the teacher-recruited childrenonly;that is, only those teacher-recruitedchil-dren who still had an anxiety diagnosis at posttreatment hadsignificantlyhigher RCMAS Lie scale scores than children whowere diagnosis-free. Thus, it appears unlikely that these childrenwere accurately reporting on their levels of anxiety.

Ournumbersdid notprovidesufficientpowerforanalysisofallpossible interactions ofgender, age,and specificdiagnosisonintervention outcome. Thus, analyses were restricted to ex-amination of maineffectsof age (younger:7-10years; older:11-14 years), gender, and preintervention diagnosis (GAD,SAD,simple phobia, socialphobia),andratesofbeingdiagno-

Table4CBCLandRCMAS Scoresfor the Intervention andMonitoring GroupsatPre-andPostinterventionandat 6-Month Follow-Up

CBCLExternalizing

TscoreTime andgroup

PreinterventionMonitoringIntervention

PostinterventionMonitoringIntervention

6-Monthfollow-upMonitoringIntervention

M

46.5149.6647.4848.6846.1549.23

SD

9.4410.999.72

11.299.11

12.50

InternalizingTscore

M

58.7661.2855.2557.1552.8456.05

SD

8.5611.74

9.0311.469.66

12.34

RCMASM

17.1516.9811.4611.529.579.25

SD

5.736.927.007.326.357.45

Note. CBCL=ChildBehavior Checklist;RCMAS=Revised Chil-dren'sManifestAnxietyScale.

sis-free atpostinterventionand6-month follow-up.To dothis,weconducted chi-square analysesfor theentire sampleandthenwithin the interventionand monitoring groups separately. Nosignificant effects werefound forage, gender,or pretreatmentdiagnosis for any of the groups at either postintervention or6-month follow-up.

DiscussionThemainaim ofthis studywas toevaluateacombinedchild-

andparent-focused intervention for prevention and early inter-ventionforanxiety problems.Theresults were very promising.Therateof recruitment into the project (7% of total screenedpopulation) was comparable with the 9%recruitment of thepopulation achievedbyJaycox,Reivich,Gillhan,and Seligman(1994)intheirstudyofpreventionofdepressivesymptomsinchildhood. Attendanceatinterventionsessionswashighfor thechildren themselves (approximately80%),moderate (approxi-mately58%)formothers,andlowerforfathers (approximately30%). As a group, children who received theinterventionemergedwithlower ratesofanxiety disorderat6-monthfollow-up, compared with those who were identified but monitoredonly. Of those who had features of, but no full disorder, atpretreatment(n =33),54%progressedto adiagnosabledisor-der at the6-month follow-upin themonitoring group, comparedwithonly16% in theintervention group. These results indicatedthat theinterventionwassuccessfulinreducing ratesofdisorderinchildrenwithmildtomoderate anxiety disorders, aswellaspreventing theonsetofanxiety disorders inchildrenwithearlyfeatures of a disorder. The differences at 6-month follow-upbetween thegroupsonratesofdiagnosable disorder were rein-forced bydifferencesinratingsofimprovementon themeasuresofchildandfamily adjustment.

The finding thatover halfof thechildrenin themonitoringgroup whowereatrisk progressed intoaformal anxiety disorderat the6-month monitoring period highlights theimportanceoflate childhood andearly adolescence as a critical timein thedevelopment ofanxiety disorders. Anumberofstudies (e.g.,Keller etal.,1992) reported that many anxiety disorders havetheir onset aroundthistime, andthat, without treatment,maypersist well into adulthood. Furthermore, studies have demon-stratedtheeffectivenessoftreatmentforthisagegroup (Barrettetal.,1996; Kendall,1994).Thus, researchers interested in the


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634 DADDS, SPENCE, HOLLAND,BARRETT, AND LAURENSdevelopment, prevention, and treatment of anxiety disorders maybe well advised tofocuson the late childhood period.

Atpostintervention, differences betweenthegroups werenotfound consistently acrossthediagnostic measures. Theratingsmeasures pointedtosuperior childandfamilyadjustmentin theinterventiongroup. Although there was a trend toward superior-ityof the intervention group, statistical differences between theratesof diagnosable disorder across groups did not emergeuntilthe6-month follow-up.Aputative delayinintervention effectsisconsistent withtheresultsof asimilar prevention trial(Jaycoxetal., 1994). However, a strong qualification isneededin con-cluding thatnodifferences between groups occurredatpostin-tervention.Because oftiming constraints,ourpostinterventionevaluations had to be conducted during the school summer vaca-tion. During the diagnostic interviews at this time, parents fromboth groups reported that manyof thechildrenwith separation,social, and performancefearshad temporarily improved becauseofnot having to face the daily challenges of school life. Thistemporary improvement of both groups and, thus, the lack of astatisticaldifference between thegroupsatposttreatment couldhave been associated with temporary changes inschoolatten-dance, and the 6-month follow-up results may be more trulyindicativeof thestatusof thechildrenin therespective groups.

The intervention effect found on the diagnosticand ratingmeasureswas not replicated on theself-report measures.TheCBCLand the RCMAS have demonstrated reliability and valid-ity;however, a previous treatment outcome study with similaranxiouschildren reported less sensitivitytodifferent interven-tion outcomes on these self-report measures, despite strong dif-ferential treatment effects on diagnostic measures (Barrett etal., 1996). Furthermore, evidence was found that method ofrecruitmentmayhave beenassociatedwith highsocialdesirabil-ity in children's self-reports of anxiety.That is, children whoself-reported low anxiety but were identified byteachers hadhigherRCMAS Lie scale scores atpretreatment.Of this group,those who failed to improve at posttreatment were similarlymore likely to have higher lie scores. Thus, there may be agroup of anxious children who do not readily acknowledgetheir anxiety problems; multiple informants may be necessarytoidentifythemandextra attentiontoengagementandtreatmentprogress withthese children may be beneficial.

Anumberoffurther discussionpointsrelateto theinterven-tion. It is not clear what characteristics of the intervention wereresponsible for its success, as the intervention included a rangeof child- and parent-focused strategies. Forthe sake of effi-ciency, itwillbe important to conduct component analyses ofthe intervention with children at various stages of developmentof, and risk for, disorder. Previous research byBarrett et al.(1996) indicated that there may be age and gendereffects interms of children's response to child- and family-focused inter-ventionsforanxiety problems.Inthis study,wefoundno effectsof age, gender, orpreinterventiondiagnosison diagnostic out-come. Apart from thepositive main effect associated withre-ceivingtheintervention,allchildren appearedtoshowasimilarcourse in the development of their anxiety problems. Barrett etal.'s(1996)finding wasthatthese demographic variables mightinfluence responsiveness to individual- versus family-basedtreatment. The present studyfounddemographic variables had

littleinfluenceon responsiveness to an intervention containingboth individual andfamily involvement.

Our screening procedure warrants discussion. Although thepresentstudywas not designed to produceestimatesof rates ofanxiety problemsin thepopulation, theidentification procedureindicatedapproximately 1 in 6children between7 and 14yearsoldeitherhad adiagnosableanxietydisorderor hadfeaturesofone.Thescreenismore proneto theexistenceoffalse-negativesthanfalse-positives.Theself-report measuresdetectedthepro-portion of girls in the general population, but teachers weremore likely to nominate boys than their representation wouldpredict. There may be a number of reasons for this. Boys maymake more of apublicor disruptive show of theiranxietyprob-lems, teachers may consider anxiety to be more of a probleminboys, or teachers may be more attentive to boys in the class-room. Girls wereoverrepresentedin thediagnosticcategoriesofGAD, SAD,andsimple phobiabutwererepresentedat thepopulation rateforsocial phobia.Assignificantly more reportsofsocial phobia camefromteacher nominations than self-report,thepresentstudyindicates thatthesalienceofanxietydisorderstoteachersmay be, inpart,associated withthegenderof thechildren showing the problems.

The method of recruitmentthat is, teacher nominations orchildren's self-report, orbothmade little difference to theratesof actual anxiety disorder detected.Approximately 55%ofchildren identifiedby each recruitment method were foundtohaveananxiety disorder,and afurther 16% to 25% of theother children showed anxietyproblems characteristic of themajor anxiety disorders but ofinsufficient severity or range towarrantadiagnosis. Thus,therecruitment methods used appearto be highlyuseful, complementing screening procedures foridentifyinganxious children inthat approximately 75% ofchil-dren identified by each method were found to have anxietyproblemswiththe use of aformal interview validation.

Therate of concordance betweenteachers' and children'sreports was quite low. Of the361childrenfoundto have anxietyproblems using either criteria, only 33 (9.14%) appeared onbothteachers' lists and their own self report. Given that eachrecruitmentmethod resulted in high detection rates of childrenwithanxiety disorders andproblems andthateachmethodde-tecteddifferent types of anxietyproblems,both methods mayneed to be used inparallelinfuture clinicalstudiesif compre-hensive detectionofanxiety problemsis to be achieved.

Althoughanumberofstepswasusedtoscreenoutchildrenwithconductandhyperactivity problems, these problems werestillevidentin thesampleidentified byself-reportandteachernominationsbefore the formation of intervention groups. Thisreinforces the conclusions ofPerrinand Last(1992),whofoundthat self-report measures of childhood anxietydo not clearlydiscriminate between children with anxietydisordersand thosewithattentiondeficit-hyperactivity disorder. In support ofthis,the percentage of children with attention deficit-hyperactivitydisorder and oppositionalproblems was higher in the grouprecruited through self-report than in the group recruited throughteacher nominations.

Time andresource restraints meantsomelimitationsto thestudy. Diagnostic interviews werenotconducted withapropor-tionof the 'nondetected'' children.Thiswould have yieldedmore conclusive dataon theadequacyof the screeningproce-


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PREVENTION OFANXIETY DISORDERS 635

dure.Furthermore, parents werethesoleinformants ofdiagnos-tic statusandbecause therewassome lossofparticipants enter-ing thediagnostic interview, some biasmayhavebeen intro-ducedthroughselective lossofchildren withorwithout anxietyproblems.

The projectraisesseveral ethicalissues.First, given that chil-dren in themonitoring group wereatrisk for,oralready had,ananxiety diagnosis, safeguardshad to bebuilt intothedesignsothatindividualhelpwasalways availableifneeded.Second,teacherswere asked to nominate children with psychologicalproblems, raisingtheissueofdetrimental labelingeffects.Third,contacting parents regarding their child's participating in agroup educational program (or passive monitoring program)mayinadvertently convey that their child has a problem. Thus,toboth parents andteachers, participation in the interventionwasdescribedas apositive skill-building experience ratherthana remedial treatment, whereas participationin themonitoringgroupwasdescribedas aninformation-gathering/learning exer-ciseforresearchers.

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ReceivedMarch 13, 1996Revision receivedJune19,1996

AcceptedJanuary14,1997

dadds spence 1997 prevention and early intervention for anxiety disorders jconsulting clinical...

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