Anxiety disorders in children
“Anxiety disorders are among the most prevalent mental problems in childhood and adolescence affecting ny as 10% – 21% of all children and youth. This estimate indicates that 1 in 5 children and youth or 4 to 6 students within a classroom of 30 children are at risk ‘for experiencing an anxiety disorder. Further, the World Health Organization has stated that obesity, early onset diabetes, anxiety and depression disorders will be more prevalent in Western countries than any other health problem in the next 30 years. Once present, childhood anxiety disorders tend to be chronic and recurrent and remit without treatment. In addition, many children experience clinical levels of anxiety will experience more than one disorder with recent estimates suggesting that 65% to 95% of anxious children and youth will experience comorbid anxiety disorders. Childhood anxiety also has a strong association with depression and childhood anxiety disorders may actually precede the development of depression with studies indicating that 22% to 44% of anxious children and youth also experience depression. Given the significant relationship between anxiety and depression and the precedence of anxiety disorders, effectively treating anxiety in childhood and adolescence may help reduce the likelihood of a depressed mood in later life (Kendall, Safford, Flannery-Schroeder, & Webb, 2004).
Unfortunately, most children and youth who suffer from anxiety will not actually receive clinical intervention (Olfson, Gameroff, Marcus, & Waslick, 2003) and for those who do many will terminate before program completion, some will relapse, and others will fail to respond to treatment (Barrett and 011endick, 2004). Additionally. anxiety disorders in childhood are frequently overlooked as the symptoms are often unrecognizable. Anxious children tend to be shy, cooperative, compliant, and may be present as the ‘perfect” child within the school setting and when away from home. Increased attention is usually given to children with disruptive behaviours as they more clearly interfere with daily life functioning, home life and school life (Albano, Chorpita, & Barlow, 2003). Anxiety can become a chronic condition for many anxious children and can subsequently affect several areas of their life including academic performance, social interaction, self-confidence, and the ability to enjoy everyday life experiences (Barrett, 1999). Disruptions in their academic performance tend to occur as anxious children may find it difficult to start and complete tasks due to the fear that their work will not be good enough. These children tend to be highly perfectionist and often experience a heightened dependence upon others which can be seen through their constant reassurance seeking and needed approval from others (i.e, peers, parents, and teachers). Such a child may continually ask the teacher, “Is my work okay, did I do a good enough job?” or their friends, “Am I still your best friend today?” Anxious children tend to be overly sensitive to criticism, have low self-esteem (Barrett, 1999) and usually become preoccupied with their worries and the uncomfortable physiological arousal that accompanies them (hyperventilation, nausea, sweating, loose bladder, etc.). School refusal is commonly seen in anxious children as they display difficulty in attending and staying in school often resulting in a complete avoidance. Such effects of childhood anxiety often lead to strained relationships between the child and their peers, parents, and teachers and, if left untreated, can often lead into depression in adolescence.
The FRIENDS program has an extensive evidence-base and is the only anxiety program that is supported by the World Health Organisation as an effective program for the prevention and treatment of anxiety and depression in children and youth (World Health Organization, 2004). The program has been disseminated around the world and is currently used in Mexico, Hong Kong, New Zealand, the Netherlands, Germany, Portugal, Finland, Norway, UK, USA and Canada.
The FRIENDS program is a positively focused program which aims to increase social and developmental skills through the use of cognitive-behavioural techniques. The program allows for easy implementation at all levels of prevention, early intervention and treatment. It can be offered as a selective, indicated and universal program within the community or school setting. The FRIENDS program can be delivered with ease by health professionals, teachers and school counsellors following an accredited training workshop. Teacher training workshops can be organised through Pathways Health and Research Centre in Brisbane, Australia (www.pathwayshrc.com.au).
The FRIENDS program includes two developmentally tailored workbooks for use with children (aged 7-11 years) (Barrett, 2004) or youth (aged 12-17 years) (Barrett, 2005), a leader’s manual with the content and process of each session, and can be run in both group and individual settings. The FRIENDS program consists of 10 weekly sessions and two booster sessions which can be held 1 month and three months following the . completion of treatment (or at a convenient time within your classroom). Each session is designed to run for approximately 1 to 1,5 hours. The general size for an effective group is between 6 to 10 children, which allows for adequate time for all children in the group to share ideas. In the classroom setting, it is useful to have children work together on activities in small groups (of 4 or 5 children) with an adult helper (e.g. teacher, teacher’s aid, parent, older student) and then return to the large group for a general discussion. The use of co-facilitators/ helpers within the classroom is very helpful in managing the group process and in assisting children who may have any reading or writing difficulties.
The program utilizes the acronym “FRIENDS” to help children remember the strategies they learn to manage their anxiety. The FRIENDS acronym (Barrett 2005) stands for:
Remember to Relax. Have quiet time.
I can do it! I can try my best!
Explore solutions and coping step plans.
Now reward yourself! You’ve done your best!
Don’t forget to practice.
Stay calm for life!
The word FRIENDS highlights the main objectives and themes of the program. Children are encouraged to: 1) think of their body as their friend as it tells them when they are feeling worried by giving them clues (physiological and somatic response); 2) to be their own friend and to look after their body through emotional regulation exercises; 3) to talk to their friends when they are in difficult situations and to help others when they are in difficult situations, and; 4) to reward themselves when they’ve tried their best.
The FRIENDS program incorporates several important cognitive-behavioural components that are based on skill acquisition, including; 1) psycho-education regarding feelings; 2) understanding the physical expression of anxiety and how to use relaxation skills: 3) cognitive restructuring and positive self-talk; 4) problem-solving skills and graded exposure for achieving goals and facing fears; 5) the importance of self-rewards and trying hard. achieving goals, and: 6) relapse prevention and learning how to maintain skills for life. The booster sessions facilitate the generalisation of skills and help children to apply the FRIENDS skills to everyday situations and future challenges.
The FRIENDS program also includes a family skills component which involves parents during each stage of the program. A collaborative “team” approach is emphasized within the FRIENDS program where the facilitator, parent(s), siblings and the children work together with a shared goal of increasing confidence and coping skills, The family component of FRIENDS is aimed at empowering everyone in the family to recognise their skills and strengths and to use these skills to help one another become more confident and brave. Parents are educated about the development of anxiety in childhood and the distinction between normal developmental fears and anxiety disorders. Parents are taught about the identification of the risk and protective factors of anxiety; they learn strategies to recognise and manage their anxious children: and they learn how to recognise and modify negatively reinforcing parenting practices. Parents learn about the FRIENDS skills during the two structured parent sessions which are outlined in the current editions of the leaders manuals (Barrett, 2005). It is recommended that program leaders conduct 2 comprehensive parent sessions which comprise the entire content of the program. Within the school setting it may be difficult to attract some parents to the parent sessions so it is recommended that the sessions be held during convenient times for the parents (e.g. during lunch, immediately after school, in the evening). In the treatment setting (e.g. private health clinic) parents are actively involved in every session as they usually join each session (group or individual) for the last 30 minutes to discuss the skills that were taught. Parents are encouraged to work with and practice the FRIENDS skills through the “family homework” activities that are assigned at the end of each session. Parents are encouraged to take an active role in the program as research has indicated that the inclusion of parents in program implementation has a positive impact on the treatment of anxious children.
Due to the large evidence-base and extensive results indicating that the FRIENDS program for children and youth is effective, the next logical step in research was to develop the FRIENDS program for an even younger age. The Fun FRIENDS program (Barrett, 2007), is a downward extension of the pre-existing FRIENDS program targeted for children aged 4 to 6 years. Research reviews strongly suggests that the preschool years are essential for building social-emotional skills (Heckman, 2000). Children who are socially and emotionally well adjusted do better at school, have increased confidence. have good relationships, take on and persist at challenging tasks and communicate well (National Research Council and Institutes of Medicine, 2000).
The Fun FRIENDS program was initially trialled at Pathways Health and Research Centre and was then piloted within several local preschools within Brisbane, Australia. During this trial within the preschools. feedback was obtained from teachers, parents, and children. in order to improve the original program. The revised version of Fun FRIENDS (2007) is currently being run at Pathways Health and Research Centre — Brisbane and has a large emphasis on experiential play and exercises.
The Fun FRIENDS program focuses on developmentally sensitive cognitive-behavioural techniques to teach children social-emotional learning to increase resilience and decrease emotional distress. The developmentally tailored CBT skills include: teaching children cognitive problem-solving skills for dealing with interpersonal challenges; recognising and dealing with body clues (i.e. physiological arousal) through breathing control and progressive muscle relaxation; cognitive restructuring (recognising and changing unhelpful red thoughts to helpful green thoughts); attention training (looking for the positive, happy aspects of a given situation); graded exposure to fears (creating coping step plans), and family and peer support.
The Fun FRIENDS program targets three major areas of social-emotional learning curriculum; 1) Self Regulation: the ability to adjust to new situations, awareness of own feelings and the ability to manage emotions; 2) Responsibility for self and others: demonstrates self-direction and independence, respects and cares for the classroom or group environment, follows routine and rules; and 3) Pro-social behaviour: plays well with others, recognises others feelings and responds appropriately, shares, respects the rights of others and uses thinking skills to resolve challenges and conflicts. The program incorporates all the above skills and each session corresponds with one of the three curriculum areas mentioned for social-emotional development. The program is 10 sessions, although, each session is broken down into 15 minute learning activities (4 to 5 learning activities for each session), so that the program objectives are reinforced daily through experiential, play -based activities such as the use of play, dramatic role-play story telling, music, movement and art.
In sum, the FRIENDS program has a strong evidence-base and has been shown to be both an effective treatment and preventative intervention, for children and youth with anxiety and depression. Research to date indicates that one in five adults and children suffer anxiety or depression (more prevalent than drug use, attention deficit disorder, or any other mental health problem) but only 5% of cases receive intervention. Suicide is the NUMBER 1 cause of death in Australia in the 15-34 years age group, and Queensland together with the Northern Territory have the highest incidence of suicide in Australia, (Australian Bureau of Statistics , 2005). We all have an ethical obligation to intervene and promote preventative and effective treatment strategies for our children and youth.”