NIHR Signal An anxiety prevention programme is not effective over the long term in UK primary schools

Published on 18 January 2016

This NIHR funded trial of an anxiety prevention programme in UK primary schools found it was effective after one year if led by health practitioners, but not after two years. The programme was not effective at all if led by a teacher. After two years, anxiety had reduced a similar amount for both the intervention group and controls, who received the usual curriculum, including personal, social and health education (PSHE) lessons. The nine-week programme, delivered in the classroom, is based on cognitive behavioural therapy (CBT) and leads nine- and ten-year-olds through activities and tasks that, through changing the way they think, help them to counter their anxieties. The cost of the FRIENDS programme was estimated to be from £52 to £56 per child and was unlikely to be cost-effective in UK primary schools in its current form. The findings suggest there is limited evidence to support implementation of the FRIENDS anxiety prevention programme in UK primary schools.

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Why was this study needed?

Anxiety disorders affect around 10% of children by the age of 16 years. They significantly impair everyday life, often persist into adulthood and increase the risk of other psychiatric disorders. The economic and societal costs are considerable and rising. NHS service costs for anxiety disorders are projected to be £2 billion by 2026. Effective psychological interventions like CBT are available for children with anxiety disorders but surveys show only around one-third of children had sought or received specialist help.

The World Health Organization regards the FRIENDS programme as having strong evidence of effectiveness. The aim of this NIHR-funded trial was to investigate the clinical and cost-effectiveness of the FRIENDS programme, as delivered under everyday conditions by health and school professionals in UK primary schools. This is the first randomised trial of the FRIENDS programme or any similar preventative anxiety programme in UK schools.

What did this study do?

This was a cluster randomised controlled trial of 41 primary schools in the south-west of England. Schools were randomly assigned to one of three groups: school-led FRIENDS, health-led FRIENDS or the usual PSHE school curriculum. In total, the trial included 1,362 children aged 9 to 10 years.

The FRIENDS programme is a nine week, manual-based CBT intervention that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety (see Definitions tab for more details). School-led sessions were led by a teacher supported by two health facilitators, while the health-led sessions were led by two health facilitators supported by the teacher. The health facilitators were external to the school and were not mental health specialists but health professionals with a lower level of training or expertise, such as school nurses or psychology assistants. The leaders from both the health and school-led arms attended a two day training event to familiarise them with the programme.

The comparison group received usual school PSHE lessons, delivered by a single teacher.

What did it find?

  • After one year, children in the health-led FRIENDS group had a clinically significant reduction in anxiety symptoms compared to those in the school-led FRIENDS group (Revised Child Anxiety and Depression Scale score –3.91, 95% confidence interval (CI) –6.48 to –1.35). The health-led group also saw a reduction in anxiety compared to the usual school provision group (–2.66, 95% CI –5.22 to –0.09). The researchers had pre-defined a reduction of 3.6 points or more as clinically important. School-led FRIENDS groups were not found to be effective when compared to the usual school provision group.
  • After two years, anxiety had reduced across the board and there was no difference between the three groups. Less than half (43.6%) of the starting number of children were tested after two years, although baseline differences between completers and non-completers were minimal.
  • The FRIENDS programme was more faithfully implemented when health rather than school-led – not all of the core tasks and activities were delivered in the school led programmes.
  • The cost of the FRIENDS programme was estimated to be £52 to £56 per child for both health-led and school-led groups, respectively. Determining cost effectiveness in the study was difficult as the subgroup of children in whom service usage data were collected had different outcomes from those in the main trial. The team cautiously concluded there was no evidence that the FRIENDS programme was cost-effective.
  • Children enjoyed the programme and teachers felt that it provided the children with useful skills. Children and teachers liked the practical activities and group work, such as role play, scenarios and games, but felt that there was also too much passive learning, such as reading, writing and listening.

What does current guidance say on this issue?

NICE guidance from 2008 states that schools should have a comprehensive programme to help develop children's social and emotional skills and wellbeing. This should include a curriculum that integrates the development of social and emotional skills within all subject areas. These skills include problem-solving, coping, conflict management/resolution and understanding and managing feelings. This should be provided throughout primary education by appropriately trained teachers and practitioners. There is nothing in the current 2008 guidance advocating a specific programme to reduce anxiety and low mood such as the FRIENDS programme.

What are the implications?

The trial gives limited evidence to support the provision of FRIENDS - a specific anxiety prevention programme - in UK primary schools.  Health-led FRIENDS had clinically relevant benefits superior to the regular curriculum after a year, but these were not maintained after two years.

Overall, the current programme looked unlikely to be cost effective. Costing £52 to £56 per child, the FRIENDS programme may be beyond the finances available to most schools, if they were to pay for it themselves. Future work could identify whether the nine-week programme could be shortened to reduce the cost.

The manual-led programme resulted in different outcomes depending on who delivered it, suggesting this may have been an important success factor, at least in the first year. Identifying other reasons for success and failure would be valuable to the formation and or modification of future programmes.

The NIHR is funding studies that are evaluating three interventions designed to improve the wellbeing of school children. The interventions being evaluated are: “Promoting Alternative Thinking Strategies” (PATHS) to promote social and mental wellbeing among primary school children; the “Roots of Empathy” programme for improving social and emotional wellbeing; and “SHAHRP” – a school based alcohol harm reduction programme.

Citation

Stallard P, Skryabina E, Taylor G, et al. A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years. Southampton (UK): NIHR Journals Library; 2015 Nov.

This project was funded by the National Institute for Health Research Public Health Research programme (project number 09/3000/03)

Bibliography

Ford T, Goodman R, Meltzer M. Service use over 18 months among a nationally representative sample of British children with psychiatric disorder. Clin Child Psychol Psychiatry. 2003;8:37–51.

McCrone P, Dhanasiri S, Patel A, et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund; 2008.

NICE. Social and emotional wellbeing in primary education. PH12. London: National Institute for Health and Care Excellence; 2008.

World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: WHO; 2004.

Why was this study needed?

Anxiety disorders affect around 10% of children by the age of 16 years. They significantly impair everyday life, often persist into adulthood and increase the risk of other psychiatric disorders. The economic and societal costs are considerable and rising. NHS service costs for anxiety disorders are projected to be £2 billion by 2026. Effective psychological interventions like CBT are available for children with anxiety disorders but surveys show only around one-third of children had sought or received specialist help.

The World Health Organization regards the FRIENDS programme as having strong evidence of effectiveness. The aim of this NIHR-funded trial was to investigate the clinical and cost-effectiveness of the FRIENDS programme, as delivered under everyday conditions by health and school professionals in UK primary schools. This is the first randomised trial of the FRIENDS programme or any similar preventative anxiety programme in UK schools.

What did this study do?

This was a cluster randomised controlled trial of 41 primary schools in the south-west of England. Schools were randomly assigned to one of three groups: school-led FRIENDS, health-led FRIENDS or the usual PSHE school curriculum. In total, the trial included 1,362 children aged 9 to 10 years.

The FRIENDS programme is a nine week, manual-based CBT intervention that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety (see Definitions tab for more details). School-led sessions were led by a teacher supported by two health facilitators, while the health-led sessions were led by two health facilitators supported by the teacher. The health facilitators were external to the school and were not mental health specialists but health professionals with a lower level of training or expertise, such as school nurses or psychology assistants. The leaders from both the health and school-led arms attended a two day training event to familiarise them with the programme.

The comparison group received usual school PSHE lessons, delivered by a single teacher.

What did it find?

  • After one year, children in the health-led FRIENDS group had a clinically significant reduction in anxiety symptoms compared to those in the school-led FRIENDS group (Revised Child Anxiety and Depression Scale score –3.91, 95% confidence interval (CI) –6.48 to –1.35). The health-led group also saw a reduction in anxiety compared to the usual school provision group (–2.66, 95% CI –5.22 to –0.09). The researchers had pre-defined a reduction of 3.6 points or more as clinically important. School-led FRIENDS groups were not found to be effective when compared to the usual school provision group.
  • After two years, anxiety had reduced across the board and there was no difference between the three groups. Less than half (43.6%) of the starting number of children were tested after two years, although baseline differences between completers and non-completers were minimal.
  • The FRIENDS programme was more faithfully implemented when health rather than school-led – not all of the core tasks and activities were delivered in the school led programmes.
  • The cost of the FRIENDS programme was estimated to be £52 to £56 per child for both health-led and school-led groups, respectively. Determining cost effectiveness in the study was difficult as the subgroup of children in whom service usage data were collected had different outcomes from those in the main trial. The team cautiously concluded there was no evidence that the FRIENDS programme was cost-effective.
  • Children enjoyed the programme and teachers felt that it provided the children with useful skills. Children and teachers liked the practical activities and group work, such as role play, scenarios and games, but felt that there was also too much passive learning, such as reading, writing and listening.

What does current guidance say on this issue?

NICE guidance from 2008 states that schools should have a comprehensive programme to help develop children's social and emotional skills and wellbeing. This should include a curriculum that integrates the development of social and emotional skills within all subject areas. These skills include problem-solving, coping, conflict management/resolution and understanding and managing feelings. This should be provided throughout primary education by appropriately trained teachers and practitioners. There is nothing in the current 2008 guidance advocating a specific programme to reduce anxiety and low mood such as the FRIENDS programme.

What are the implications?

The trial gives limited evidence to support the provision of FRIENDS - a specific anxiety prevention programme - in UK primary schools.  Health-led FRIENDS had clinically relevant benefits superior to the regular curriculum after a year, but these were not maintained after two years.

Overall, the current programme looked unlikely to be cost effective. Costing £52 to £56 per child, the FRIENDS programme may be beyond the finances available to most schools, if they were to pay for it themselves. Future work could identify whether the nine-week programme could be shortened to reduce the cost.

The manual-led programme resulted in different outcomes depending on who delivered it, suggesting this may have been an important success factor, at least in the first year. Identifying other reasons for success and failure would be valuable to the formation and or modification of future programmes.

The NIHR is funding studies that are evaluating three interventions designed to improve the wellbeing of school children. The interventions being evaluated are: “Promoting Alternative Thinking Strategies” (PATHS) to promote social and mental wellbeing among primary school children; the “Roots of Empathy” programme for improving social and emotional wellbeing; and “SHAHRP” – a school based alcohol harm reduction programme.

Citation

Stallard P, Skryabina E, Taylor G, et al. A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years. Southampton (UK): NIHR Journals Library; 2015 Nov.

This project was funded by the National Institute for Health Research Public Health Research programme (project number 09/3000/03)

Bibliography

Ford T, Goodman R, Meltzer M. Service use over 18 months among a nationally representative sample of British children with psychiatric disorder. Clin Child Psychol Psychiatry. 2003;8:37–51.

McCrone P, Dhanasiri S, Patel A, et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund; 2008.

NICE. Social and emotional wellbeing in primary education. PH12. London: National Institute for Health and Care Excellence; 2008.

World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: WHO; 2004.

A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years

Published on 1 November 2015

Stallard P, Skryabina E, Taylor G, Anderson R, Ukoumunne OC, Daniels H, Phillips R, Simpson N

Public Health Research Volume 3 Issue 14 , 2015

Background Anxiety in children is common, impairs everyday functioning and increases the risk of severe mental health disorders in adulthood, yet few children with anxiety are identified and referred for treatment. Objective To investigate the clinical effectiveness and cost-effectiveness of a universal school-based preventative programme (FRIENDS) in reducing symptoms of anxiety and low mood. Design Cluster randomised controlled trial. Schools (n = 41) were randomly assigned after recruitment on a 1 : 1 : 1 basis to health-led FRIENDS, school-led FRIENDS and usual school provision. Setting Primary schools in three local education authorities in the south-west of England. Participants Children (n = 1362) aged 9–10 years attending school and participating in personal, social and health education (PSHE). Interventions The FRIENDS programme is a cognitive–behavioural therapy programme that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. The FRIENDS programme was led by either a trained member of the school or a health leader external to the school and was delivered over 9 consecutive weeks. The comparison group received usual school PSHE lessons. Interventions were delivered in the academic year September 2011–July 2012. Main outcome measures Clinical effectiveness assessed by child report of symptoms of anxiety (Revised Child Anxiety and Depression Scale, RCADS); cost-effectiveness based on RCADS and quality-adjusted life-years (Child Health Utility 9 Dimensions, CHU-9D) between baseline and 6 months; process evaluation, evaluation of reach and attrition and qualitative feedback from children, school staff and parents. Results At 12 months there was a difference in the adjusted mean RCADS scores for health-led FRIENDS compared with school-led FRIENDS [–3.91, 95% confidence interval (CI) –6.48 to –1.35] and for health-led FRIENDS compared with usual school provision (–2.66, 95% CI –5.22 to –0.09). At 24 months we were able to assess only 43.6% of our cohort. There were few differences in baseline characteristics between completers and non-completers. Child-reported anxiety in all three groups had reduced by 24 months and there were no longer any group effects. There were no between-group effects for any parent- or child-completed secondary outcomes at 12 or 24 months. The cost of the FRIENDS programme was £52–56 per child. We found no evidence that the FRIENDS programme was cost-effective over a 6-month period; however, our subgroup for the economic analysis differed significantly from our main trial cohort. Conclusions Although greater reductions in anxiety were noted at 12 months when the FRIENDS programme was delivered by health leaders, these additional benefits were not maintained at 24 months. Children’s anxiety levels improved irrespective of the intervention that they received. Our economic evaluation and 24-month assessment had significant shortcomings. However, the universal delivery of specific anxiety prevention programmes will result in additional costs that may be beyond the finances available to most schools. Future work should identify the active ingredients and potential moderators of universal anxiety programmes to determine whether programme length can be reduced, short-term effectiveness maintained and cost-effectiveness improved. At present, our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools. Funding The National Institute for Health Research Public Health Research programme.

The FRIENDS programme develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. Children develop emotional awareness and regulation skills to enable them to identify and replace anxiety-increasing thoughts with more balanced and functional ways of thinking, and to develop problem-solving skills to confront and cope with anxiety-provoking situations and events. The programme therefore teaches children skills to identify and manage their anxious feelings, develop more helpful (anxiety-reducing) ways of thinking and face and overcome fears and challenges rather than avoid them.

Author commentary

Improving the mental health of children is a national priority with schools offering convenient locations to provide anxiety prevention programmes. Our study shows that, when delivered under everyday conditions, an efficacious school based anxiety prevention programme had limited effectiveness and was unlikely to be cost-effective.

Further research is needed to investigate how mental health prevention programmes fit within schools, the effect of the programme leader and how short-term effects can be maintained and cost effectiveness improved. At present our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools.

Paul Stallard, Professor of Child and Family Mental Health, University of Bath