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A universal prevention program for anxiety symptoms in school aged children : taming worry dragons Short, Christina 2005

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A UNIVERSAL PREVENTION P R O G R A M FOR A N X I E T Y SYMPTOMS IN SCHOOL A G E D CHILDREN: TAMING WORRY DRAGONS by CHRISTINA SHORT B.A., University of British Columbia, 1993 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF ARTS in THE F A C U L T Y OF G R A D U A T E STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA October 2005 © Christina Short, 2005 A B S T R A C T A growing literature has investigated the efficacy of cognitive-behavioral therapy for treating children with anxiety disorders; however, there remains scant research to discover if cognitive-behavior therapy programs can be used as a preventative approach for anxiety. This study adds to the limited available research on the prevention of anxiety by implementing and evaluation a locally developed cognitive-behavioral intervention program, Taming Worry Dragons. This study examined the effectiveness of a school based cognitive-behavioral intervention for reducing rates of anxiety symptoms in children aged 7 to 12 years. Using a universal prevention approach, 162 children were randomly assigned (school as unit of randomization) to either an 8-week cognitive-behavioral intervention group or to a wait list control group. Children's anxiety levels were assessed before and immediately after the intervention by child self-report (Multidimensional Anxiety Screen for Children, March, 1997) and by parent reports (Behavioral Assessment Schedule for Children, Kamphaus, 1992). Results of the statistical analysis (ANCOVA) indicate that the manualized CBT intervention, which included relaxation training, cognitive restructuring, and behavioural components, was not successful in reducing symptoms of anxiety within the general population of school aged children. The children in the wait-list condition, however, did report significantly lower mean scores on the self-report measure. A separate wi thin-group analysis was performed, examining those children with elevated self-report scores only (T score of 55+ in treatment and WL groups). Those in the treatment condition significantly improved following the intervention (effect size of .8) while those in the waitlist condition remained unchanged. Ill T A B L E OF CONTENTS ABSTRACT .. i i T A B L E OF CONTENTS ; i i i LIST OF T A B L E S • vi LIST OF FIGURES vii A C K N O W L E D G M E N T S viii Chapter One , 1 Introduction 1 Statement of the Problem 5 Purpose of the Study 8 Chapter Two 10 Literature Review 10 Etiology 10 How Anxiety Manifests Behaviorally in School Children 19 Treatment Modalities of Childhood Anxiety Disorders 20 Prevention of Anxiety 30 School-Based Interventions and Teacher Implementation 38 Taming Worry Dragons Program 39 Summary 41 Statement of the Hypotheses 42 Chapter Three 43 Methodology 43 Participants 43 iv Intervention Program • 45 Procedure 46 Research Design 49 Data Analysis 50 Chapter Four 52 Results : • 52 Descriptive Data 52 Description of Means and Standard Deviations 52 Between Group Differences at Pre-intervention 55 Parent-Child Correlation • 55 Pre-Post Within Groups Paired t-tests 55 CBT Intervention Group versus Wait-list A N C O V A 57 At Risk Students : .' 57 Qualitative Outcome 60 Chapter Five ; 63 Discussion 63 Limitations 67 Future Research '. 69 Conclusion 70 REFERENCES 72 APPENDIX A 84 APPENDIX B. . . . . 86 APPENDIX C 90 V APPENDIX D 92 APPENDIX E 93 APPENDIX F .- 94 APPENDIX G .97 APPENDIX H 98 APPENDIX I '. 99 vi LIST OF TABLES Table 1 Demographic Data p.53 2 Means and Standard Deviations of Dependent Measures p.54 3 At Risk Students Descriptive Statistics P-57 4 Pre-Post Within Group Paired t-tests p.58 5 . Pre-Post Within Group Paired t-tests for At Risk Students p.60 LIST OF FIGURES Figure 1 Change in Anxiety Scores Vll l A C K N O W L E D G M E N T S I would like to express my thanks and appreciation for the support of my research committee. Thank you for all the careful reading, excellent advice, and encouragement for this research project. Dr. Lynn Miller and Dr. Dana Thordarson provided an immense amount of their time, clinical expertise and energy. I would also like to thank Dr. Sandra Clark and Dr. Jane Garland for their support, resources and guidance of the research project. Thank you for the donation of the teacher's manual for the implementation of this project. Thanks also to the Langley School Board for their support and acceptance of the research project. Dyan Burnell and Marion McCristall deserve thanks for the encouragement and getting the project started within the school system. A special thanks goes out to my family, friends and colleagues for their patience, encouragement, and support throughout the long process and completion of my thesis. "Anxiety is a thin stream offear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts are drained. " - Arthur Somers Roche Chapter One Introduction A l l people, from children to adults, experience feelings of anxiety, as anxiety is normal and common. Anxiety serves as a means of protection and can often enhance one's performance in stressful situations (Dinsmoor, 2002). Anxious feelings may be transitory or specific to a stage of development. For example, very young children may have short-lived fears, like being afraid of the dark, animals or strangers. Similarly, during school years, fears of strangers or school evaluations are common and normal (Piacentini & Roblek, 2002). Anxiety is a subjective sense of worry, apprehension, fear or distress. Anxiety is "a basic human emotion, characterized by a diffuse, uncomfortable sense of apprehension, and often accompanied by autonomic symptoms" (Albano, Chorpita & Barlow, 2003, p. 296), and is often triggered by the anticipation of future events, memories of past events, or ruminations about the self. When symptoms become extreme or disabling, or when a child experiences several symptoms over a period of a month or more, this may be a sign of an anxiety disorder (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM'- IV), 1994). Experiencing too much anxiety or general nervousness at inappropriate times can be extremely disruptive. Anxiety is viewed as a problem when it hinders an individual from enjoying normal life experience over a long time period (Piacentini & Robleck, 2002). Children with severe anxiety have constant worries about things before they 2 happen, such as school performances, friends, sports, and fears of embarrassment or making mistakes; as a result, their ability to handle interpersonal relationships, be socially competent, and adjust to school may be impaired. Anxiety may interfere with an individual's ability to relax or to concentrate. Sleep may be difficult as well (Child Development Institute, 2002). Only in the past two decades has research on children and adolescents with anxiety been published; this has resulted in an increase of public awareness of this particular mental health issue in children. The first formal effort to systematize the various categories of childhood anxiety disorders and specific diagnostic criteria for each category was presented in the third edition of the Diagnostic and Statistical Manual of Mental Disorder (American Psychiatric Association [DSM], 1980). The DSM-III (19S0) introduced a section on childhood and adolescent anxiety disorders, in which separation anxiety disorders (SAD), avoidant disorder in childhood or adolescence, and overanxious disorders (OAD) were outlined as the three distinct anxiety disorders of children. Numerous studies have led to changes and revisions in the criteria for diagnosis, and in a more recent edition DSM-IV (APA, 1994) childhood anxiety disorders were delineated into nine disorder subtypes: SAD, panic disorder, agoraphobia, generalized anxiety disorder, social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder and acute stress disorder. Currently, it is the DSM-1V-TR (2000) that is used by the mental health professionals in clinical practice, to distinguish between the different types of anxiety problems. Barrett (1999) however, stresses that "Before anxiety problems become serious disorders, it is not necessary to distinguish between these types of anxiety disorders" (p. 86). She emphasizes that rather, the focus 3 should be on early prevention, increasing children's "resilience and psychological hardiness" (p. 86). According to the Child Development Institute (2002), "Anxiety disorders are among the most common mental, emotional, and behaviour problems that occur during childhood and adolescence. As many as 1 in 10 young people may have an anxiety disorder. Among adolescents, more girls than boys are affected" (para. 3). Furthermore, a growing body of research indicates that anxiety disorders are one of the most prevalent categories of psychopathology in children and adolescents (Costello, 1995). Only over the past 10 years have epidemiological studies been examining the rates of anxiety disorders in children and adolescents. The prevalence rate for anxiety disorders varies according to each study. However, it appears that anxiety disorders generally are relatively common. In a review of epidemiological studies, it was collectively estimated that between 8 to 12% of young people suffer from anxiety symptoms that are severe enough to interfere with their daily function (Bernstein, Borchardt & Pervien, 1996). In other research, the estimated incidences of childhood anxiety disorders range from 10 to 22% (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Kashani & Orvaschel, 1988). Costello et al., (1988) studied the prevalence of DSM-III diagnoses in a group of children aged 7 to 11 years, who visited their physician for a variety of reasons. A sample of 300 of the 789 children and parents were interviewed to determine diagnosis according to the Diagnostic Interview Schedule for children. Prevalence rate of anxiety was 21 %. No study reports any differences in prevalence rates based on ethnicity. Kendall (1994) suggests that anxiety disorders are not transient. They do not go away easily, and in the absence of treatment can be associated with negative long-term complications. Childhood anxiety disorders typically have the onset age of 10 years and can follow a chronic course into adulthood (Keller, et al., 1992). Childhood anxiety disorders can severely affect a child's ability to conduct daily activities, perform in school, or develop relationships. Anxious children have a higher rate of absenteeism, lower classroom and extra-curricular participation rates, and they tend to have a lower classroom level of academic achievement than unaffected children (Miller, 2002; Piacentini & Robleck, 2002; Woodward, 2001). Unfortunately, anxiety disorders that begin in childhood and are left untreated may evolve into other disorders, as the child gets older. In naturalistic interviews of 275 children and their parents, Keller and colleagues (1992) ascertained that 46% of the children with anxiety disorders would be i l l eight years after the onset of the disorder if left untreated. In a longitudinal study, 1197 first-grade students were followed over four and half years. The results indicated that anxiety in the first grade significantly predicted anxiety in the fifth grade for these children. Similarly, Pine and colleagues (1998), using a previously collected data set, showed that adolescents aged nine to 18 years, who met criteria for an anxiety disorder, had a two to three fold increased risk for anxiety disorders nine years later. In addition, higher levels of anxiety were associated with lower levels of achievement (Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1994). These results do not only indicate that anxiety disorders in children may be enduring, but also suggest recognizing early and mild symptoms as important or significant. Childhood anxiety is predictive of other anxiety disorders, major depression, suicide attempts and an increased risk of failure in school during adolescence and early adult years (Pine, Cohen, Brook, & Ma, 1998; Ost & Treffers, 2003). Difficulties with anxiety are also strongly related to other important health-related behaviours. For example, a three-year prospective study of 2738 youths aged 14 to 15 years by Patton and colleagues (1998), found that symptoms of anxiety were related to higher risks of smoking through an increased susceptibility to peer smoking influence. Woodward (2001) also found an association between anxiety disordered youth and elevated rates of anxiety and depression in these youth as young adults. In this longitudinal study, Woodward followed 924 New Zealand youths, starting at age 14 to 16 years until they reached the age of 21. The results indicate that an early onset of anxiety is associated with a number of other adverse mental health and life course outcomes (alcohol abuse, nicotine dependence, suicide attempts and educational underachievement). In addition to the intrapersonal and social suffering experienced by children with anxiety, anxiety disorders also pose a significant cost to the health care system. According to a study by Greenberg and colleagues (1999), the financial cost in the U.S.A to treat anxiety disorders in children was estimated to be "approximately $42.3 billion in 1990 dollar terms, or $63.1 billion 1998 dollars" (p. 431). Statement of the Problem Given the high prevalence of anxiety in children, the possible persistence of the disorder over time, the association with depression and other distressful outcomes, and the cost to the health care system, it is important to recognize anxiety early and implement an early intervention program. Helping children deal with common anxiety issues may help to prevent the development of disorders later in life (Muris, Meesters, Merckelback, Sermon, & Zwakhalen, 1998). Despite being the most common psychological problem, anxiety disorders in young children are often overlooked which means that children do not receive adequate treatment. Excessive anxiety, social withdrawal, and shyness are common in many children 6 (Silverman & Kurtines, 1996). Because they do not overtly affect others, do not cause a disruption, and are typically "invisible," they frequently go unnoticed and untreated. Likewise, parents often overlook a child's anxiety because children may not talk about their symptoms or concerns. In contrast, externalizing disorders such as attention deficit hyperactivity disorder or oppositional difficulties tend to be more disruptive, are more easily observed, and may have a direct effect on others. Individuals affected with these disorders are frequently referred to mental health practitioners more often and have been the topic of considerable research focus (Silverman & Kurtines). In a classroom setting, anxious children are often not viewed by teachers as difficult or troublesome. These children suffer in silence because the symptoms they are experiencing may not be obvious to others around them and may be missed (Walker, 2000). As a result, they do not receive help. Miller (2002) notes that "parents and teachers frequently do not see a child's anxiety because children may not talk about their concerns or they may see themselves as oddly different from their peers" (p. 4). At the same time, children themselves usually do not recognize that they are anxious and that their worry is excessive. Children rarely tell parents or teachers about their worries. The problem is how to reach those who need the help the most. Taken together, all of these factors are "powerful forces in prompting researchers to develop ways to best intervene, reduce or remediate the ... difficulties associated with anxiety" (Lowry-Webster, Barrett, & Dadds, 2001, p. 37). Anxiety disorders in children warrant more attention from educators, parents, and researchers. It is imperative to disseminate recent research and the knowledge of childhood anxieties, so that parents and professionals can develop an understanding of anxiety, know how symptoms present in children, and therefore become more aware of the issue, if it exists. 7 Paralleling the current upsurge of epidemiological and physiological research of anxiety are empirical studies of interventions for childhood anxiety disorders. Presently, there exist both pharmacological and psychological interventions. Over the past 20 years, a series of controlled outcome studies has provided evidence for the efficacy of psychosocial interventions, mainly cognitive-behavioural therapy (CBT) treatment programs, targeting anxiety disordered children (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Kendall, et al., 1997; Kendall & Southham-Gerow, 1996). Miller (2002) reports that "Cognitive-behavioural treatment interventions have the most extensive research support in treatment, early intervention and prevention of anxiety disorders in children and adolescents" (p. 5). Walker (2000) concurs, and states that these psychosocial treatments have advantages with respects to the cost of treatment and the acceptability to parents and children. The majority of the research on childhood anxiety has focused on individual cognitive-behavioural treatment in a clinical setting (Barrett et al., 1996; Kendall, 1994; Kendall et al., 1997). Results of controlled trials show that cognitive behaviour therapy can be effective in as many as 70% of clinically anxious children (Kendall, 1994; Ollendick & King, 1998). A few studies consider group CBT (Barrett, 1998; Flannery-Schroeder & Kendall, 2000; Mendlowitz, et al., 1999; Silverman, et al., 1999) and have shown that they are comparable to individual CBT treatment. It is only recently that group CBT had been adapted and evaluated as a school-based intervention in Australia (Barrett, & Turner, 2001; Dadds, Spence, Holland, Barrett, & Laurens, 1997; Lowry-Webster, Barrett, & Dadds, 2001). Rapee (2002) states that "to date, there has been little interest in developing programs for the prevention of broad-based anxiety disorders" (p. 947). 8 In summary, there have been recent gains in understanding anxiety (e.g., prevalence, etiology) and the recognition of the adverse outcomes i f anxiety is left untreated. A significant proportion of children experience some form of anxiety disorder. In addition, far too few anxious children are being noticed and subsequently are not benefiting from any type of treatment. In an effort to address the issue of anxiety, the existing research has focused on identifying treatment approaches for anxiety disorders. Most of this research has demonstrated the effectiveness of psychosocial interventions, mainly CBT, for children with anxiety. Research into the prevention or early intervention of anxiety is in its infancy. Purpose of the Study A review of the literature highlights the efficacy of using CBT programs with children suffering with an anxiety disorder; it also highlights the fact that despite the practical importance of developing and supporting anxiety prevention programs for use with children, research into the prevention or early intervention for anxiety symptoms is sparse. Limited research and resources have been focused on preventing anxiety despite suggested promising results from previous studies; therefore,.there exists an opportunity to focus on prevention and early intervention programs with the aim of reducing anxiety symptoms in children. No study to date in Canada has examined the implementation of a CBT program as a preventative intervention with children in a school setting. With this in mind, the present study seeks to add to the very limited available research on the prevention of anxiety disorders by implementing and evaluating a locally developed CBT universal intervention program, Taming Worry Dragons (TWD), (Garland & Clark, 1995) for anxious children in a school-based group setting. The research will compare the efficacy of the CBT treatment group with a wait-list control group. The CBT protocol, Taming Worry Dragons, is an 9 anxiety treatment model that was developed by Dr. Jane Garland and Dr. Sandra Clark, from the Mood and Anxiety Disorders Clinic at B.C.'s Children's Hospital. To date, this program has been utilized by Provincial mental health teams and by other hospitals in BC. This program has claimed effectiveness when used in a clinical setting, but has not yet been evaluated with children in a non-clinical setting. Walker (2001) argues, that for anxiety problems, "Prevention is the approach with the greatest promise in dealing with large scale public health problems" (p. 3). Spurred by interest in being able to prevent anxiety, the present study will use a quantitative approach in an attempt to answer the question: "Does the Taming Worry Dragons program reduce symptoms of anxiety in school-aged children?" The study will present preliminary data on the efficacy of TWD as a universal school-based preventive intervention for childhood anxiety. 10 Chapter Two Literature Review Anxiety is consistently defined as a set of emotional reactions coming from the anticipation of a real or imagined threat to oneself (Fonseca & Perrin, 2001). Anxiety is expressed as a fear of an event that a person perceives as dangerous, overwhelming, or unmanageable. A l l of us experience worry and anxiety. But in contrast to normal worries, an anxiety disorder is seen as being beyond that which is expected for a child's development level, out of proportion to the threat posed, and is severe enough to cause distress, or is persistent, and impairs one or more areas of functioning (Albano, Chorpita, & Barlow, 2003). Within the past 20 years, considerable progress has been achieved in understanding the phenomenon of anxiety in children. An increasing number of articles and books have been published which describe the etiology, diagnosis, assessments, and interventions for this group of disorders. In reviewing the relevant literature related to anxiety disorders in children, the chapter will begin with a brief summary of anxiety in children, etiology and symptom presentation, and will proceed by reviewing the clinical treatment procedures used in research. This is followed by a discussion of the need for more research into the prevention of anxiety. Research has tended to focus on clinical trials of children who have been diagnosed with an anxiety disorder. Limited research on prevention of anxiety with non-clinical children will be reviewed. The final section of the chapter introduces the program that was validated in the research project, Taming Worry Dragons (TWD). Etiology Before looking at ways to treat anxiety, it is necessary to review how anxiety develops and how it presents in children. Understanding the factors involved in the 11 development of anxiety provides a basis for a discussion of the various treatment modalities and programs, which have been developed in the past decade to assist children in coping with their anxiety. In a report for the B.C. Ministry of Children's and Family Development, Waddell and Shepherd (2002) reviewed six epidemiological studies in order to provide an update on the prevalence of mental disorders in children and youth. Their review showed that the prevalence rate for any anxiety disorder in children and youth is 6.5%, this figure currently equals 60,900 children in British Columbia. Experts debate the question of whether anxiety disorders are caused by psychological or biological factors. It remains to be seen what factors play a role in the etiology of childhood anxiety. Researchers have advanced several theories to explain the etiology of anxiety disorders. The available literature suggests a variety of factors, alone or in combination, which appear to be related to development of anxiety disorders: heredity, familial, environment factors, stressful life events, and cognitive appraisal may all play a role. Temperament. One risk factor is a biological predisposition to anxiety disorders. Researchers have examined the relationship between early temperaments, (mainly social inhibition), in children and the later development of anxiety disorders (Kagan, Reznik, & Snidman 1987, 1988; Rosenbaum, et al., 1991). Kagan, Reznick, and Snidman (1988) child development psychologists, have focused on the issue of temperament, suggesting that some children may begin their life with certain personality traits that make them more susceptible to the development of anxiety problems. Such researchers assert the notion that those who display the characteristic of being socially inhibited may be disposed to later anxious 12 symptomatology, and in fact, these vulnerable individuals can be identified during the first years of life (Kagan, Reznick, & Snidman, 1988). Behavioural inhibition is the temperamental characteristic that has received the most study; this is the tendency to be unusually shy or to show fear and withdrawal in new and/or unfamiliar situations (Rapee, 2002). Caspi, Henry, McGee, Moffitt, and Silva (1995), conducted a 12-year longitudinal study on 800 children to examine the relationship between early temperamental traits and the later development of internalizing symptoms. They found that the early temperamental traits of passivity, shyness, and fear, and being avoidant in new situations were related to the exhibitions of anxiety in later years. Biological Factors. A second factor is a family history of anxiety. The literature provides evidence for a genetic/biological basis in the development of anxiety. Boer and Lindhout (2001) assert that "anxiety disorders run in families" (p. 235), and there are several studies showing evidence of genetic influence (for example, Andrews, Stewart, Allen & Henderson, 1990). In another study, Last, Hersen, Kazdin, Orvaschel, and Perrin (1991) investigated psychopathology in first and second-generation relatives of children with anxiety disorders. Results demonstrated that relatives of clinically anxious children showed a higher prevalence of anxiety than of both relatives of normal controls and relatives of children with A D H D . Other studies suggesting a family influence showed that parents with anxiety disorders have children that are also more susceptible to diagnosis (Beidel & Turner, 1997). Taken together, these studies have demonstrated that children are more likely to be anxious i f they are born to anxious parents, lending support for the possibility of a biological 13 transmission of anxiety. However, Turner, Beidel, Roberson-Nay, and Tervo (2003), in a review of genetic/biological studies, make the comment that, "None of the studies reported the direct transmission of a specific anxiety disorder" (p. 542). The mechanism for the relationship has not been proven as to whether biology (genetic factors) or environment (parenting style, interactions, learning) plays the greater role in the development of anxiety (Turner et al., 2003). According to Thapar and McGuffin (1995, as cited in Cobham, 1998), as much as 40-50% of the variance in anxiety symptoms may be explained by genetic influence. Parenting. A third possible risk factor in the development of childhood anxiety disorders is parenting style. Parental overprotection, overcontrol, and criticism/lack of warmth are parenting characteristics that have been identified in the literature as possible risk factors in the development of childhood anxiety (Rapee, 2002). Much of the work looking at parenting styles and interactions stems from Bowlby's (1969) attachment theory, "which posits the relevance of unsuitable or disrupted parenting styles as a determinant of anxiety" (Albano, Chorpita, & Barlow, 2003, p. 314). Rapee (1997) summarized the literature examining parenting styles and anxiety in children, and demonstrated a link between overly involved, controlling, and critical parenting styles and anxiety. In a later review, Rapee (2002) acknowledges that most of the results from the studies are less than ideal due to a reliance on the use of retrospective designs and from a reliance on self-reports; however, he continued to assert that, "The literature showed a surprisingly consistent association between anxiety in offspring and perceived overprotection and criticism from parents. Of these factors, there was a small but consistent indication that the stronger association was between anxiety and parental overprotection" (p. 951). Barrett, 14 Rapee, Dadds, and Ryan (1996), for example, studied the extent to which family interaction influenced children's interpretations of unknown situations and their coping behaviour. In their observational study of anxiety disordered children (n=152, age 7 to 14 yrs) and their parents compared with a control group (n=53), they found that children with high anxiety were associated with having parents who give more negative feedback about possible physical and social threats and dangers. This parent-child interaction may influence the child to then overestimate potential threats and danger. They also demonstrated that the anxious children "increased the likelihood of reporting avoidant coping responses to a hypothetical situation of ambiguous threat following a discussion of the situation with their parents" (p. 201). However, the oppositional and control group of children showed a decrease in avoidant responses following the family discussion. The authors proposed that parents of anxious children have a tendency to teach their children to interpret and respond anxiously to ambiguous threat cues, and in turn they teach their children to use avoidant solutions when faced with ambiguous hypothetical social situations. In a more recent study, Hudson and Rapee (2001) used an observational design to examine the interaction between clinically anxious children (N =43), oppositional defiant children (N =20) and non-clinical children (N = 32), and their mothers. Ninety-five children (aged 7 to 15 years) and their mothers participated in the study. The researchers asked the participating children to complete several complex cognitive puzzles. The purpose of the study was to examine the mother's involvement (control) and the general negativity of the mother-child interaction (rejection) on the children's ability to complete the cognitive tasks. The mothers were in the room while their children were solving the puzzles, and were instructed to help only if their child really needed it. The results demonstrated that the 15 mothers of the anxious group were more involved and more intrusive than the mothers of the non-clinical group and that they were also were more negative (used criticism) in their interaction with their child than mothers of the non-anxious children. The results lend support to parenting styles characterized by control and rejection and anxiety. In summary, these studies show the role of parenting behaviours (particularly critical and over protectiveness) as a possible factor in the development of anxiety in children. Cognitive Processing. A final factor involved in the development of anxiety disorders is cognitive processes. There is a growing body of research which points to the role of cognitive distortions and deficiencies in the etiology and/or maintenance of childhood anxiety. A cognitive-behavioural approach to childhood anxiety development emphasizes the underlying mechanisms to be negative, distorted and maladaptive cognition (Prins, 2001). A basic assumption of the "...cognitive models of psychopathology of emotional disturbances such as anxiety... [is that it] stems from faulty or negative ways of thinking" (Beck, 1976 as cited by Weems, Berman, Silverman, & Saavedra, 2001, p.559). Therefore, it is believed that, "Anxiety results from an individual's tendency to interpret all events and experiences in a negative, catastrophic, and irrational manner, such that the individual overestimates the probability of threat and underestimates his or her ability to cope with a situation" (Albano & Morris, 1998,p.207). Chorpita, Albano, and Barlow (1996) were interested in exploring the nature of cognitive processing among children with anxiety. Their study's participants consisted of 12 children (five boys and seven girls ages 9-13 years) and their families. Four of the children represented the clinical sample, after being diagnosed with an anxiety disorder, through the child and parent forms of the Anxiety Disorders Interview Schedule for Children (ADIS-C 16 and ADIS-P; Silverman, 1991). The remaining eight children represented the non-clinical sample. A questionnaire was administered to each child individually: a set of four situations was given in which the child had to verbally express his/her interpretation of the situation and what he/she would do or how she/he would react to the situations, to assess whether anxious children demonstrated an interpretive processing bias for threat. The results revealed what the authors hypothesized: that anxiety-disorder children showed a heightened bias toward interpreting ambiguous situations as threatening, provided avoidant action plans when confronted with ambiguity, and ".. .assigned higher probability to the occurrence of threatening events" (p. 174). The authors demonstrated that anxiety in children is associated with threat-based interpretations of uncertain situations. As one of the few empirical studies looking at children's cognitions, this study suggests that an interpretative bias is a possible phenomenon among anxious children. This helps to draw researchers' attention to the cognitive processes that may play an important role in the etiology and/or maintenance of childhood anxiety. It also represents an important link to the effective use of cognitive-behavioural therapy with anxious children because CBT works to increase a person's awareness of both his/her thinking patterns, and behaviours. In a similar study, Bogels and Zigterman (2000) examined whether a group of children with social phobias, separation anxiety disorders, and generalized anxiety disorders had a negative cognitive bias in comparison to both a clinical control group of children (with oppositional disorder (ODD), attention deficit and hyperactivity disorder,(ADHD), and conduct disorder (CD)), and a non-clinical sample. Forty-five children (15 in each group sample) were presented with nine stories; three described a separation story, three a social threatening story and three a generalized anxiety story. The children were asked to first 17 indicate what they would be thinking (open-ended question) and then to choose from multiple choice questions how they would be feeling, thinking, and how they would respond in the situation (closed-questions). The findings in the study were: (1) the children in the anxious sample explained uncertain situations with a more negative connotation; (2) their explanation of the ambiguous situations demonstrated a higher perceived possibility of danger and threat, and a lower perception of having any influence over the dangerous situation; and (3) anxious children tended to underestimate their ability to cope in a situation which they perceived to be dangerous. Overall, they had a negative view and negative thoughts with regards to their capabilities to deal with a possible threat. This study lends further support to the cognitive theory of anxiety as they found that anxious children do have a cognitive bias: they overestimate the likelihood of threat. Bogels and Zigterman (2000), propose that: [tjhis is an important finding for the development of specific cognitive therapies for anxious children. It suggests that cognitive therapy in children with social phobia, separation anxiety, and generalized anxiety should be directed toward modifying negative cognitions about one's own behaviour in the face of possible threat, and toward building self-esteem. Also, other forms of therapy that focus on modification of negative thoughts about own competence, like social skills training, could contribute to the efficacy of cognitive therapy in children (p. 210). In examining the cognitive errors characteristic of children with anxiety disorders, Weems and colleagues (2001), using a sample of children and adolescents (n=251; age 6-17 years) who were referred to their clinic due to difficulties with fear and/or anxiety, administered the Children's Negative Cognitive Error Questionnaire (CNCEQ; Leitenberg et 18 al., 1986) to assess negative errors associated with anxiety. This clinical study focused on the relations between anxiety and four types of cognitive errors (catastrophizing, overgeneralization, personalizing, and selective abstraction), while controlling for depression. Results indicated that "Catastrophizing, overgeneralizing and personalizing [are] potentially important negative cognitive errors in the anxiety of children with anxiety and phobic disorders....These results extend the literature by suggesting that the variance in anxiety predicted by cognitive errors such as catastrophizing, overgeneralization and personalizing is not completely mediated by depressive symptoms and thus that cognitive errors have a unique relation with anxiety" (p. 572). This study provides further evidence indicating that cognitive errors are related to anxiety in children and youth. In general, anxious children tend to judge threats as more serious (overgeneralizing and catastrophizing), and underestimate their own coping ability, tend to perceive they have no control over threat, and tend to report more cognitive errors than non-anxious children. It seems unclear whether this negative cognitive bias is responsible for anxiety or is a result of it. Either way, it may be an influential factor for maintaining anxiety symptoms; these findings lend support to a cognitive model of anxiety based on the premise that emotional disturbances, such as anxiety, are characterized by faulty or negative ways of thinking (Prins, 2001). In summary, several factors for the development of anxiety have been identified, each with extensive investigation efforts and support. The etiology of anxiety disorders remains perplexing as they involve a complex interplay of biological, familial, environmental and cognitive variables. 19 How Anxiety Manifests Behaviorally in School Children Anxiety is considered to be a tripartite construct in which anxiety reactions generally involve a physiological response, a cognitive response, and a behavioural response (Albano & Kendall, 2002). The physiological response is characterized by heightened autonomic arousal, ". . . which are often reflected in the self-report of multiple somatic complaints (Fonseca & Perrin, 2001, p. 127). This occurs in the form of increased heart rate, dizziness, sweating, nausea, tightening of muscles, headaches and quick breathing. These responses are the body's way to prepare it for the 'fight or flight' response (Cannon, 1929) when exposed to a stressful situation. The cognitive response is characterized by worrying or distorted cognitions about threat, one's performance or safety. Often what is going through a child's mind are fear-inducing thoughts or ideas (e.g., "I am going to make a fool of myself!", "What if they laugh at me?", "They don't like me!") or terrifying images (e.g., an accident happening, their parents getting murdered). Cognitive symptoms can also be presented an inability to concentrate, poor memory, or rigid and critical thinking patterns. The behavioural component depends on how an individual responds to the stress in flight or fight response; often in the presence of a threat/stress, anxiety is demonstrated by "flight" or avoidance behaviours, sleep difficulties, restlessness, crying, or clinging to caregivers (Fonseca & Perrin, 2001). A child may also display other behaviours by "fight," for example, impulsivity, oppositional defiance, aggression or finally, freezing in a complete 'shut-down.' 20 Treatment Modalities of Childhood Anxiety Disorders The research literature on interventions for use with anxiety disorders in children has made considerable advancement in recent years in developing a solid knowledge base. The purpose of this section is to review the status of the treatment research literature in this area, which at the present time is either psychopharmacology treatment or psychosocial treatment (CBT). Psychopharmacology. The literature on evaluating pharmacological treatment for anxiety disorders in children is sparse and the evidence mixed (March, 1999). Commonly considered medications for anxiety in children includes tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and benzodiazepines. The use of pharmacotherapy for adults with anxiety has become well established, with the SSRIs being the first-line treatment of choice. As with adults with anxiety, SSRIs appear to hold the most promise in the pharmacological treatment of anxiety in children (Birmaher, et al. 1994), despite the paucity of outcome studies demonstrating their effectiveness in anxious children (Birmaher, Yelovich, & Renaud, 1998). In a review of pharmacological treatment by Walkup, Labellarte, and Ginsburg (2002) for childhood anxiety disorders, the authors note that pharmacological treatment studies in childhood anxiety disorders have "come some distance" (p. 135) since the first trials in the 1960s. However, "Most of the medications have been used clinically with children, but only a few medications have a Food and Drug Administration (FDA) indication" (p. 135). Furthermore, March (1999) states that "apart from OCD. . . few empirical studies of the efficacy, much less safety, of specific medication have been conducted, with the use of many compounds in the pediatric population supported solely by clinical lore" (p. 42). In March's review of the pharmacotherapy for childhood 21 anxiety, it is demonstrated that "most of the available evidence favoring drug treatment represents expert clinical opinion rather than controlled or even open trials" (p. 45). In a review of pharmacological agents used to treat anxiety disorders, Kutcher, Reiter, Gardner, and Kein (1992) stated that most studies that examined the efficacy of medications were challenged by methodological limitations. For example, they argued that there is a lack of double blind, placebo-controlled studies that have evaluated the efficacy of pharmacological treatments with anxiety disorders. Instead, Kutcher and colleagues found that most studies were open trials using a small sample size; therefore, there is lack of ability to generalize findings to larger populations. Other methodological limitations are due to studies using different dosages, concurrent therapies with the medication trial, and studies using different duration of medication treatment. Hawkridge and Stein's (1998) study showed effectiveness for both tricyclic anti-depressants and benzodiazepines in some childhood anxiety disorders, but they raised concerns about the risk of cardiac arrhythmias with tricyclic anti-depressants and addiction with use of benzodiazepines. The authors suggest that pharmacotherapy be reserved for severe anxiety disorders and the risk/benefit ratio be carefully evaluated, because long-term side effects have not been studied in children or adolescents. March (1999) asserts that medication treatment may have a stabilizing effect and may used first to offer relief of symptoms, but medication use is only part of the treatment process. Danton, Altrocchi, Antonuccio, and Basta (1994) outline in their article six reasons why they caution the use of medication as a treatment for anxiety: (1) medications may alleviate anxiety symptoms, but they do not necessarily cure the underlying problem; (2) anxiety may stem from child efforts to avoid feeling anxious, so the medication may only prolong the avoidance behaviour; (3) 22 reliance on medication may encourage patients to accept the state instead of active problem solving; (4) some anxiolytics may impair learning; (5) Some patients are not comfortable taking mind-altering medications and would prefer non-drug alternatives; and (6) at moderate levels, anxiety is an important motivator and alerts us to danger, so we do not want to eliminate anxiety. These authors advocate for the use of non-drug treatment. In summary, at present it appears that SSRIs are the medications of choice and widely used mainly due to their low side effect profile. Commonly used SSRFs include fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox). However, there are very few studies examining the efficacy and safety of these agents in children, and the long-term safety remains to be assessed (Stock, Werry, & McCleellan, 2001). Researchers do not know the optimal duration of treatment as most studies have not addressed long-term treatment outcomes. In general, pharmacological treatment tends to be controversial as there is uncertainty regarding its appropriateness of use with children. Psychological Intervention. The emergence of psychosocial treatment for childhood anxiety disorders has only occurred since the 1980s. Southam-Gerow (2001) stated that: Although historically a wide range of therapeutic modalities has been applied to treat anxiety in children, the lion's share of the recent empirical work has focused on behavioural and cognitive-behavioural approaches. The recent review of the child anxiety treatment research by Ollendick and King (1998), applying criteria for empirically-supported treatment (Chambless et al., 1996), found that only behavioural and cognitive-behavioural approaches currently met some of the American Psychological Association's Division 12 (Clinical 23 Psychology) Task Force on Promotion and Dissemination of Psychological Procedures (Div. 12 Task Force; 1995) criteria (p. 239). Research has shown cognitive-behavioural therapies (CBT) to be the most useful treatment for anxiety. CBT teaches children to cope directly with their symptoms, and how to think about worries in a less catastrophic way. CBT is a brief, structured, direct, and problem focused treatment that addresses a child's somatic (physical complaints), cognitive (negative, biased thinking), and behavioural (crying, clinging, avoidance) problems (Piacentini & Roblek, 2002). This approach is aimed to increase a range of cognitive and behavioural skills. CBT is the treatment of choice for most children as it has no adverse side effect or withdrawal problems, and its effects can be maintained long term; it also is associated with a lower rate of subsequent relapse, can enhance self-esteem and help lead to an increased sense of agency (Gould, Otto, Pollack, & Yap, 1997). The behavioural component of CBT is based on the notion that worries are learned and thus can be unlearned; therefore, the goal of behaviour therapy seeks to change a child's reaction to anxiety provoking situations, increasing a child's engagement in behaviour that gives positive reinforcement and avoiding negative reinforcement. Cognitive therapy recognizes that thoughts and feelings underlie behaviour; thus, the goal of cognitive therapy is to teach children to become aware of what are often pessimistic and negative thoughts, to recognize physiological and psychological indicators of emotional distress, and to reappraise the way to process this information (Ollendick & King, 1998). Thinking patterns are examined and modified in order to facilitate changes in behaviour and affect. CBT with anxious children is based on the "premise that [they] view the world through a 'template' of threat, automatic questioning (e.g., "What i f . . . " ) , and behavioural avoidance" (March & 24 Albano, 2002, p. 422). Various treatment strategies, either alone or in combination, are used to assist the child in developing a new "coping template": cognitive restructuring, correction of maladaptive self-talk, problem-solving skills, relaxation training, anxiety management training, imagery, exposure role-play rehearsals, and reinforcement (Ollendick & King, 1998). Initially, studies established the effectiveness of individual CBT (ICBT) in treating children's anxiety disorders. At least nine controlled studies have indicated efficacy for cognitive-behavioural therapy, showing that CBT can be effective in as many as 70% of clinically referred children with anxiety (Kendall, 1994; Kendall et al., 1997; Kendall & Southam-Gerow, 1996; Ollendick & King, 1998). Evidence of the effects of ICBT on childhood anxiety is encouraging. Kendall (1994) was the pioneer both in developing a manualized CBT program for anxiety disorders in children and providing empirical support for ICBTs efficacy relative to a wait-list control condition. In Kendall's (1994) first study, 47 children (60% boys) aged between nine and 13 years with a diagnosis of either overanxious disorder (n=30), separation anxiety disorder (n=8), or avoidant disorder (n=9) were involved in either a 16-session cognitive-behavioural program called the Coping Cat, or an eight-week wait-list control condition. Of the participants, 76% were Caucasian, and 24% were African-Americans. The ICBT program (the Coping Cat Workbook) included modeling, exposure, role-playing, relaxation training, cognitive self-statements, and reinforcement. The author paid particular attention to describing the methodology and procedure used in the study. Utilizing a variety of instruments, data was collected from the children, their parents, teachers and clinicians, both pre-treatment, post-treatment, and at a one-year follow-up. To help establish validity, at 25 the end of the treatment the author obtained information concerning therapeutic alliance (Child's Perception of Therapeutic Relationship) and parental involvement with the therapists throughout the treatment. The study (Kendall, 1994) found that at both post-treatment and the one-year follow-up, there was clinically significant improvement in 65% of the sample. The ICBT group, compared with the wait-list, was associated with positive changes reported by both child- and parent reports, observations of children's behaviours and diagnostic status. Follow-up data, gathered one year after the trial was complete, suggested that the treatment gains were maintained. In a further follow-up, 33 of the original participants (2-5 year follow-up, X =3.35 years) were reassessed using checklists, a child self-report assessment, and a structured diagnostic interview with their parents. The long-term follow-up demonstrated that the treatment group maintained their gains, as the percentage of cases that did not meet diagnostic criteria was consistent (Kendall & Southham-Gerow, 1996). In a second randomized-controlled trial, Kendall and colleagues (1997) reaffirmed the efficacy of ICBT with 94 children (ages 9 to 13 years) who were randomly assigned to ICBT (n=60) or wait-list (n=34) groups. A battery of self-, parent-, and teacher-report questionnaires were administered pre-treatment, at post-treatment, and at a one-year follow-up. Their results demonstrated that 71% of the children in the treatment group did not meet diagnostic criteria at post-treatment, in comparison to only 5.8% of those children in the wait-list control who did not meet diagnostic criteria. Maintenance of gains, on numerous measures and observations, was evident at the one-year follow-up, with many of the youths experiencing greater improvements over time (Kendall et al., 1997). 26 Further evidence for ICBT's beneficial effects in reducing anxiety in children with a diagnosis of an anxiety disorder was provided by Barrett, Dadds, and Rapee. (1996). They were able to replicate Kendall and colleagues' (1996, 1997) positive findings with a sample of Australian youth. Their sample of 79 children, who were clinical patients with either a diagnosis of over anxious disorder (n=30), separation anxiety disorder (n=30), or social phobia (n=19), ranged in age from 7 to 14 years. The children were randomly assigned to 12-week ICBT (n=28), 12-week ICBT plus family component (n=25), and 12-week wait-list control (n=26) groups. The CBT program used in this study was the Coping Koala Workbook (an Australian adaptation of Kendall's (1994) Coping Cat Workbook), which "specifically targets the child's anxiety using exposure and cognitive restructuring strategies" (Barrett et al., 1996, p. 335). Favorable changes were found in self-, parent- and teacher-reported anxiety measures and in anxiety observational measures. Immediately following treatment, 57.1% of the ICBT treatment group did not meet diagnostic criteria for an anxiety disorder, while only 26.1% of the wait-list control children were diagnosis free. At both the six-month and 1-year follow-ups, 71.4% of the ICBT group were diagnosis free, once again "demonstrating the effectiveness of using cognitive-behavioural procedures with anxious children" (p. 340). Overall, these controlled, between-group design studies provide empirical evidence for the efficacy of ICBT in children with anxiety disorders. This has resulted in a well-established treatment and support for manualized (CBT) treatment producing therapeutic change (Ollendick & King, 1998). Recently, there has been an increasing interest in evaluating the efficacy of adapting the same CBT protocols to a group format (GCBT) for treatment with anxious children and 27 youth. GCBT has the advantage of delivering needed treatment to larger numbers of anxious children. Other rationales for the use of group treatments include, "cost-effectiveness (for both therapist and family), natural opportunity for exposure to feared social situations, normalization of anxiety, and positive peer influence in group process" (Southam-Gerow, 2001, p. 243). Barrett (1998), investigated the effectiveness of CBT in-group format for childhood anxiety disorders; it also examined the benefit of having an additional parental involvement condition. Sixty children (32 boys and 28 girls, 7 to 14 years of age) through referrals from community centers, schools, mental health professionals, and doctors, were randomly assigned to the GCBT condition (n=23) or a wait-list control condition (n=20). This study used structured interview procedures to assess the children's diagnostic criteria, and used multi-source assessments to assess treatment outcomes. The manualized treatment used was the Coping Koala Group Workbook, an adaptation of Kendall's (1994) Coping Cat Workbook. At post-treatment, Barrett (1998) was able to demonstrate that "Group interventions for childhood anxiety proved as effective as individual interventions both at post-treatment and 12-month follow-up" (p. 466). The results indicate that the 64.8% of children in the GCBT condition no longer met DSM-III-R (APA, 1987) criteria for an anxiety disorder, as compared to only 25.2% in the wait-list control group. At the one-year follow-up 64.5% of the children in the GCBT were diagnosis free. Using the same treatment design, a study by Mendlowitz and colleagues (1999) attempted to replicate Barrett's (1998) study. This Canadian study addressed the effect of group cognitive-behavioural treatment with or without parental involvement on clinically anxious children. While this study was examining the benefit of having parents involved in the treatment, the first hypothesis was that "Group-based CBT for childhood anxiety disorder 28 will result in improvement on all of [the] measures" (Mendlowitz et al., p. 1224). Sixty-eight children (29 boys, 39 girls; 7 to 12 years of age) who met criteria for one or more DSM-IV (APA, 1994) anxiety disorders were referred to the Toronto Children's Hospital. In this study, families were randomized to either a child GCBT only, parent group only, or combined treatment with child and parents groups, with a waiting-list control condition. The treatment manual used in this study was the Coping Bear Workbook, a 12 chapter manual that "roughly parallels the concepts presented in the [Coping Cat Workbook] treatment manual but include[s] additional behavioural strategies" (Mendlowitz et al., p. 1225). Consistent with Barrett's findings, the investigators demonstrate the effectiveness of treating children with anxiety disorders in-group CBT format (either with or without family involvement) relative to the wait-list condition. Further empirical evidence for the efficacy of GCBT to treat children with anxiety disorders was reported by Silverman and colleagues (1999). The investigators used Coping Koala with a U.S. sample of 56 children (34 boys and 22 girls, 6 to 16 years of age) with the treatment outcomes being measured by three child- and three parent-report measures (in comparison to Barrett - using only one). The children were randomly assigned to GCBT condition with concurrent parent sessions, or wait-list control condition. Findings indicate once again that CBT can be used in a group format with clinically anxious children as "64% of the children in the GCBT were recovered at post-treatment (i.e., no longer met primary diagnosis) compared with 13% of the children in the wait-list control condition" (p. 1001). These treatment gains were demonstrated to be maintained at a 3-, 6-, and 12- month follow-ups representing a "further step toward empirically establishing that GCBT meets the criteria established by A P A ' s Task Force as a 'probably efficacious' treatment procedure" (p. 1001). 29 Finally, Manassis and colleagues (2002) recently reported the results of a randomized trial evaluating the efficacy of group CBT and ICBT. The study provides further evidence for the efficacy of GCBT in treating children (aged 8 to 12 years) who met DSM-IV (APA, 1994) criteria for diagnosis of generalized anxiety disorder, separation anxiety disorder, simple phobia, social phobia, and panic disorder. This is the only study to directly compare the effects of ICBT and GCBT with no wait-list control condition. In their study, they assigned 78 anxiety-disordered children to either individual or group treatment conditions. Children in both conditions met weekly for 12-weeks and received the Coping Bear Workbook treatment program. For children in the GCBT conditions, their parents had concurrent sessions, while children in the ICBT condition had their parents join them for the last 45 minutes. This study demonstrated that GCBT was equally effective as ICBT. Further support comes from Muris, Mayer, Bartelds, Tierney, and Bogie (2001) who also found that both treatment formats were equally effective in reducing children's anxiety disorder symptoms. However, they stated that GCBT was preferable due to being both cost and time efficient. In summary, all of the clinical trials summarized in the preceding sections demonstrate the efficacy of CBT, either in individual or group format, for reducing anxiety disorders in children, with the positive benefits shown to have been maintained in one to three year follow-ups. Although the data that have been gathered from these studies are significant, investigations were limited to clinical populations, or children who were diagnosed with an anxiety disorder and needed to be treated 30 Prevention of Anxiety Barrett and Turner (2001) argue that "Treating children who are already experiencing significant anxiety problems may not be the most effective or efficient means of reducing the incidence of childhood anxiety in the general population" (p. 400). Hence, Barrett and colleagues (2001) have identified prevention "as the most important direction in which these services should move. The prevention of anxiety seeks to target a large number of individuals over a short period of time, and reduce the large financial costs to communities at large" (p. 37). Rapee (2002) supports this argument by recognizing that many young individuals who have an anxiety disorder may suffer for years before parents seek help and that only a small proportion of families obtain help; therefore, children may face years of impairment and complications before they are brought to attention and referred. Rapee advocates for an alternative to intervention, the alternative being primary prevention programs. Prevention is "basically taking action to (1) prevent development of a problem, (2) identify problems early enough in their development, (3) reduce unnecessary suffering, and (4) utilize a myriad of interventions to restore, enhance, or promote resistance resources for at-risk populations" (Klingman, 2001, p. 371). Ideally, prevention is proactive and occurs before the onset of a disorder, to prevent problems in unaffected young people; this is what is often referred to as primary prevention (Barrett & Turner, 2001). In this context, primary prevention can be aimed at three levels: (1) applied across a whole population, no matter their risk status (Universal intervention), (2) applied to individuals with early indicators or symptoms of a disorder (Selective intervention), and (3) applied to individual who display 'at-risk' factors for a disorder (Indicated intervention) (Barrett & Turner, 2001). The premise of prevention is that preventive interventions will improve a child's skills for coping with 31 common anxiety, alleviate any current symptoms, and increase a child's resiliency, which should help mitigate the severity of future dysfunctions and development of disorders later in life (Barrett & Turner, 2001). To date there is little research or resources related to primary prevention of anxiety disorders. It has only been recently that interventions using cognitive-behavioural techniques have been examined using community samples of children as prevention for the onset of anxiety disorders in randomized trials (Barrett & Turner, 2001; Dadds, Spence, Holland, Barrett, & Laurens, 1997; Lowry-Webster, Barrett, & Dadds, 2001). One of the first examples of a prevention program for anxiety disorders is the Queensland Early Intervention and Prevention of Anxiety Project (Dadds, et al., 1997). Dadds and colleagues (1997) were the first to study the adaptation of the CBT treatment protocol as a prevention/early intervention program in a community cohort of anxious children. The main aim of the study was to evaluate the efficacy of a CBT program as an early intervention and prevention program with children who were "disorder-free but showed mild anxious features to those who met criteria for an anxiety disorder but were in the less severe range.. .referred to as at risk" (p. 628). Initially, 1,786 children from grades 3 to 7 (ages 7 to 14 years) in primary schools in Australia were screened for the presence of anxiety problems using a child-self report (Revised Children's Manifest Anxiety Scale; R C M A S ; Reynolds & Richmond, 1985) and by teacher nominations. After further screening and diagnostic interviews with the parents, 128 children were selected to participate. Participants were children who met DSM-IV (APA, 1994) criteria for an anxiety disorder (moderate severity), or showed signs of anxiety while not meeting full diagnostic criteria but not at levels deemed clinically severe. After recruitment, children were randomly assigned to 32 a 10-week school-based GCBT and parent-based intervention or to a monitoring group. The children in the treatment condition met in groups from 5 to 12 children, for 1- to 2-hour sessions and received lessons based on The Coping Koala: Prevention Manual. This program is identical to The Coping Koala: Treatment Manual (Barrett, Dadds, & Rapee, 1996). Parents of the children in the intervention condition met for three parental sessions during weeks 3, 6, and 9. The monitoring group did not receive any intervention; they were only contacted at post-intervention and follow-ups. Results of this study (Dadds et al. 1997) show that at post-intervention there were no significant differences between the GCBT and monitoring group as they both showed improvements, but at the 6-month follow-up only the intervention group continued to show improvement. At 6-month follow-up, the children in the intervention group had lower rates of anxiety disorders; 16% of the children in the intervention group met criteria for an anxiety disorder in comparison to 54% of the children in the monitoring group. In addition, the intervention group demonstrated better outcomes on the clinician rating measure at the 6-month follow-up. In 1999, the authors conducted a 1- and 2-year follow-up, and it was found that at the 2-year follow-up, results favored the intervention group as their improvements were maintained with only a 20%) rate of anxiety disorders (Dadds, Holland, Barrett, Laurens, & Spence, 1999). Thus, the results suggest that early intervention may reduce the rates of anxiety disorders. A limitation of the Dadds and colleagues (1999) study was the approach used to evaluate the prevention program. In the study, children were selected for the intervention program based on being 'at risk' of developing anxiety disorders. The authors' aim was to provide intervention to a range of children, from those who were disorder free, to those who 33 meet criteria for anxiety disorder, but were in the less severe range. However, 75% of the selected children did meet the criteria for an anxiety disorder at the screening process. As Sweeny and Rapee (2001) contend, "Results from these children are not relevant to the issue of prevention/early intervention and simply reflect treatment of mild anxiety disorders" (p. 180). In terms of primary prevention, the main interest should center on the children who either are at risk of developing anxiety symptoms (due to family history or events) or show symptoms of anxiety but do not meet criteria for anxiety disorder at pre-treatment. Prevention literature notes that using selected programs has more disadvantages; for example, one disadvantage is the possibility of not identifying appropriate children to receive the intervention who may need assistance (due to false-negative errors). The authors comment that although the selective intervention shows promise, further investigation is needed to focus on prevention offered to all children in a school. Another disadvantage is the possible stigmatizing effect that can be created by being selected and labeled as "as risk" for anxiety. Another issue that limits the study includes the fact that the program was administered by specialized staff and trained clinical psychologists; therefore, it is still a costly intervention and has only "...demonstrated efficacy under ideal staffing conditions" (Lowry-Webster, Barrett, & Dadds, 2001, p. 39). Recent work by Barrett and Turner (2001) provides a notable contribution to the area of prevention research, as they provide the first study examining universal programs for preventing childhood anxiety. Universal prevention is characterized by children and families who do not seek help and children are not singled out for the intervention. A l l children in a setting (or area) receive the intervention; therefore, universal intervention may be effective in 34 capturing the children who periodically show elevated anxiety symptoms but do not meet criteria for an anxiety disorder although they could become 'at-risk' at another point in time. Barrett and Turner offer sound reasons for considering universal strategies for anxiety prevention with children. Specifically they believe it has the potential of benefiting a larger number of students as it eliminates the chance of missing children who need assistance through false-negative errors on the screening measures. In addition, this intervention is less stigmatizing; no one is singled out as having a problem. Another advantage mentioned by Offord, Chmura, Kazdin, Jensen, and Harrington, (1998) is that "Although universal programs cannot be expected to have a large effect on individuals, they may have a small effect on almost all members of the population, which translates into a large effect on the population as a whole" (p. 690). In summary, universal prevention has the potential to be of enormous benefit in terms of reducing the prevalence of mental disorders, such as anxiety disorders (Donovan & Spence, 2000). The specific aim of Barrett and Turner's (2001) study was to determine if a universal prevention intervention would be efficacious for a range of children -from those who were disorder free but displayed mild anxious symptomatology, to those who met the criteria for a moderate anxiety disorder. The study also evaluated the efficacy of having the program delivered via teachers rather than psychologists. The authors believed that the research was important based on the contention that early intervention may be a more effective means of addressing anxiety problems. The program being evaluated was Friends (Barrett, Lowry-Webster, & Holmes, 1998a), an Australian group-based CBT early intervention and treatment program, based on Coping Koala. Friends is a 10-week program specifically designed for school-aged children. It has the core components of a CBT program, including 35 cognitive strategies, relaxation, and exposure. Additionally, it encourages children to think of their bodies as their friend, to be a friend to themselves, to make friends with others and to talk with friends when they are in a worrisome situation. The program helps children develop skills and techniques to cope with and manage anxiety, while also incorporating a family support component. The participants in the study were initially 588 grades six children (297 boys and 291 girls) aged 10 to 12 years from 10 metropolitan Catholic schools in Brisbane, Australia. The participants were mainly from English speaking, Anglo-Saxon families. Seventy-five percent were from dual-parent homes, while 11.55% reported single-parent households. However, as a result of incomplete or incorrectly completed questionnaires, the data from only 489 children were subsequently analyzed. Each school was randomly assigned to one of three conditions: psychologist-led treatment condition, teacher-led treatment condition, or a monitoring condition. Data were collected from the children using standardized tests at both pre- and immediately at post-intervention. The Spence Children's Anxiety Scale (SCAS), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Children's Depression Inventory (CDI) were used as self-report ratings. Researchers performed one-way analyses of variance to compare the differences for each intervention condition across the two time periods for each measure. Additionally, the data were analyzed for any significant gender effects at pre-and post-intervention. The study found that the Friends program (Barrett & Turner, 2001) was effective as a school-based universal program for decreasing anxiety symptoms among school-aged children. A l l children who received the intervention, whether the program was delivered by 36 either a teacher or a psychologist, showed improvements on the self-report measures of anxiety from pre- to post-intervention. On both the follow-up assessments, the intervention groups "...demonstrated a significantly stronger decrease in self-reported anxiety compared with the monitoring group" (p.405). The authors contend that the findings lend support to intervention programs being successfully delivered in a school-based setting. Concurrent with Barrett and Turner's (2001) study, Lowry-Webster, Barrett, and Dadds (2001) conducted a parallel study, which also researched the implementation of a universal prevention trial. The authors were not only exploring the effectiveness of the prevention program on levels of anxiety symptomatology but also its effects on depressive symptomatology at post-intervention, in comparison with a wait-list group. The participants in the study were 594 children from grades 5 to 7 from seven metropolitan Catholic schools in Brisbane, Australia. Each school was randomly assigned to a treatment condition or wait-list condition. A l l children in the treatment condition (n=392) received the Friends program, which was delivered as part of the school curriculum during school hours by the classroom teachers. Lowry-Webster and colleagues postulated that, " A l l children can benefit from such skills-building programs, which accordingly might bolster intervention effects through the general enhancement of interpersonal functioning in a school community" (p. 39). The results from the study (Lowry-Webster, Barrett, & Dadds, 2001) provide added support for the promise of school-based CBT interventions for reducing rates of anxiety symptomatology. Children in the treatment condition, compared with those in the wait-list condition, demonstrated a decrease in symptoms, regardless of their risk status. In addition, 75.3% of the children who were at-risk at pre-treatment and received the Friends program no 37 longer reported anxiety symptoms within the clinical range at post-treatment compared with 45.2% of the wait-list group. Considered together, Barrett and Turner (2001) and Lo wry-Webster, Barrett, and Dadds (2001) were successful in delivering a CBT group intervention to schoolchildren using a universal prevention approach. These studies suggest that conducting universal prevention CBT programs at schools by school staff is feasible, and can have positive benefits in ameliorating rates of anxiety problems. In addition, the authors were able to address some of the problems that arose in Dadds and colleagues (1997) research, such as the expense of using specialized staff, attrition rates, and labeling. However, in both studies the authors acknowledge that the findings are only preliminary, as a limitation of both studies is the reliance on assessing only immediate effects of the intervention. Another issue to consider when interpreting their results, as the authors cite, is the exclusive reliance on children's self-report measures. Without multi-method assessments, it can be argued that the findings may have limited validity. Further limitation includes no specific demographic data. For example, no mention was made of cultural group identification, or the number of boys or girls in the final data pool. The demographics of samples in Canada may be quite dissimilar from this Australian data; as a result, the study may have limited generalizability to Canadian populations. Lastly, an ethical limitation, not outlined in the studies, is that the monitoring and wait-list conditions did not received the Friends program upon completion of the treatment trial. The authors argue that all children can, and probably should, benefit from the skill-building, resilient enhancing program; however, they did not give the program to a large number of children who also displayed anxious symptomatology. 38 Despite the shortcomings in the above reviewed studies (Barrett & Turner, 2001; Lowry-Webster, Barrett, & Dadds, 2001), all build on previous research by producing more detailed information consistent with earlier findings on the effectiveness of CBT programs for reducing anxiety in children. What is significant about the studies is that the authors attempt to shed some light on the possibility of offering an intervention program within the general population of school-aged children; the authors did not exclude any children from learning the skills necessary to enhance their mental health and thereby help to immunize themselves from anxiety disorders. The strength of the studies also comes from the authors' provision of a strong rational for the importance of the studies; the context for the studies was well developed. As well, the description of their procedures was detailed enough to make replication feasible. School-Based Interventions and Teacher Implementation Walker (2000) not only advocates for the need to develop preventative programs, he too believes that such programs would best be suited to 'community settings' such as the school system. The Barrett and Turner (2001) and Lowry-Webster and colleagues (2001) studies provided empirical evidence for teacher's effectiveness in delivering the intervention in the classrooms. School intervention for anxiety has practical significance, for several reasons. First, the school environment is a rich and innovative setting for the implementation ofa CBT program because this is where teachers and educators observe and interact with children consistently. Teachers are in a unique position to help identify anxiety in children and to implement early intervention. Second, school is the children's natural environment so having treatment in this setting "should provide optimal opportunity for meaningful change" (Masia, Klein, Storch, & Corda, 2001, p. 783). Children who have acquired anxiety 39 management skills in a clinical setting may have difficulty generalizing them to their natural environment. Furthermore, the teachers will know what skills and techniques the children are learning, and therefore, can assist in encouraging them to use specific techniques when needed or to help them practice. Third, by allowing school staff to disseminate the intervention program through the classroom it becomes "a cost- and time-efficient means of service delivery" (Barrett & Turner, 2001, p. 401). Finally, having the intervention in school provides access to peer support; talking about anxiety while experiencing mutual support from their friends may provide the children with a sense of acceptance, sense of belonging and a decreased sense of isolation as their fears are normalized. The school setting thus provides children with social exposure and peer feedback (Scapillato & Manassis, 2002). Taming Worry Dragons Program Similar to the Friends (Barrett, Lowry-Webster, & Holmes, 1998) program, Taming Worry Dragons (Garland & Clark, 1995) also applies all the components of CBT. According to Garland (2002), Taming Worry Dragons "adapts [the CBT components] with imaginative features that are appealing to children" (p. 29). The program uses positive reframing and creative imagery to conjure up the idea of "worry dragons" that are in children's minds and therefore, need to be tamed using a variety of tools taught in the program (Garland, 2002). The implication in the program is that "worry dragons" need to be tamed, not slayed, because anxiety is an adaptive emotion and behaviour, at controlled levels. Therefore, the focus is on "trapping" tools: for example, thought stopping, relaxation, distracting oneself with exercise and activities, and compartmentalizing with a schedule. The program teaches children to cope with anxiety using physiological, cognitive, and behavioural strategies. 40 Both the Friends and Taming Worry Dragons programs are grounded in a cognitive-behavioural theoretical orientation. Both programs rely on the CBT model in the cognitive (thought), the physiological (body), and learning (behaviour) processes involved in the development and maintenance of anxiety. An interesting difference between the two programs is a cultural one. Friends was developed in Australia. Therefore, the language of the Friends program is specific to the Australian culture. For example, the program uses words such as "mates," "outback," and "tucker," which are all Australia specific. The animals referred to in the book are native to Australia (e.g., platypus and a bilby). The main character in the book is a Koala: an animal very familiar to children from Australia. Because of the above reasons, and the fact that the program often makes references to the Australian landscape, children from other countries may well have difficulties relating to what is being said. Taming Worry Dragons on the other hand is a locally developed program that uses language, pictures, and images familiar to North American children. There is a cost advantage to using a local program as well, because locally produced programs avoid high shipping and copyright costs. An additional benefit of using and promoting locally produced materials is the support this provides to future initiatives of research on topics such as anxiety. Currently, the Taming Worry Dragons program is available only as a 'clinical' group leader's manual. However, there are many schools counsellors and other school staff in the Lower Mainland of the British Columbia school board system, which use the Taming Worry Dragons program informally. Research within the hospital setting has demonstrated significant improvements in the reduction of anxiety-specific symptoms from pre-treatment 41 to post-treatment, with gains maintained at 6-month (S. Clark, personal communication, August 8, 2005). As Taming Worry Dragons has only been used in clinical settings, the manual and workbook had to be modified for classroom use specifically for this study. The Taming Worry Dragons program originally presumed a familiarity with anxiety, both as a mental health issue, and with running clinical mental health groups for children. The revised manual presumed that each classroom teacher had excellent classroom management skills, and emphasized these skills in the new manual. The manuals were reformatted by providing an introductory section on information about anxiety, establishing a table of contents, constructing a common formula for each session (e.g., appropriate warm-up, new skill, review of last week's lesson, etc), suggesting classroom tips for implementation, anticipating time allotments for each activity, and providing pre-produceable materials for the children's detective work (homework). The clinical language used in the original TWD was removed, and was replaced with more teacher "friendly" language, such as changing "clinical levels of disorder" to "elevated symptoms of anxiety." A l l modifications were then submitted to the primary authors for review. I made all revisions that eventually became the classroom teachers' manual. The modified manual as presented to the classroom teachers, as well as the children's workbooks, reflected more than eight months of revisions, which were necessary in order to make the classroom manual suitable for teachers. Summary This review of the literature has covered the prevalence rates, background of anxiety in children, treatment, prevention and implementing programs within the school setting, as 42 well as the introduction of the program to use in the project. Etiology of anxiety includes genetic transmission, parenting factors and cognitive processes. Treatment modalities for anxiety include psychopharmacology, but evidence has emerged suggesting that CBT is the treatment mode of choice. However, the majority of studies focus on clinical populations within a clinical setting and omit a large number of sub-clinical children who may never receive clinical intervention. Limited progress has been made with respect to prevention procedures for childhood anxiety. Three relevant studies that focus on prevention of anxiety disorder were presented. An examination of school-based treatment with children who have sub-clinical levels of anxiety symptoms, found that anxiety symptoms could be reduced. Statement of the Hypotheses The purpose of the present study was to evaluate the efficacy of a universal school-based intervention, Taming Worry Dragons, for reducing symptoms of anxiety in school children. It was hypothesized that the children in the intervention group would have lower rates of anxiety symptoms at post intervention, compared with the children in the wait-list condition, as measured by self-report and parent reports. 43 Chapter Three Methodology Participants Thirty-five elementary school principals (K-7) in the Langley school district (#35) were addressed via a presentation on the research project at the district school board office in June 2004. Of the 35 elementary schools, 17 expressed interest and were then invited through a written invitation to have their Grades 4, 5, and/or 6 classes participate in the anxiety prevention research program (see Appendix A). Three of the Langley district schools were selected based on first schools to respond to the study, by faxing in the signatures of both the school administrator and the participating teachers. The schools, rather than the participants, were selected as units of random assignment. Schools were randomly assigned to either receive the Taming Worry Dragons program or to the wait-list control. Parents of all children (n= 162) from the Grade 3, 4, 5, 6, and/or 7 classes were informed of this project by a letter (see Appendix B) and were asked to give their consent for their children to participate (see Appendix C). The letters were sent home by their classroom teacher and were returned to the classroom in a sealed envelope. A l l children in the classroom received the program, but only children with consent had data used. Data collected were to screen for anxiety symptoms using self- and parent-report measures. The final sample of participants in the study consisted of 118 students (44 children did not have consent to participant in the study): 75 students in the Taming Worry Dragons intervention group and 43 in the wait-list group. Of the 118 participants, 59 were female and 59 were males. The average age of the students that participated in the study was 9.75 years with a range of 7 to 12 years, (2.5 % 7 years, 11% 8 years, 25% 9 years, 32%> 10 years, 27% 44 11 years and 1.5% 12 years of age). The students ranged from grade three to grade seven (10% in grade 3, 28% in grade 4, 29.7% in grade 5, 29.7 in grade 6 and 2.5 % in grade 7). Criteria for participation in the program included: (1) consent from parents, (2) fluency in English, and (3) student willingness to participate in the eight-week psycho-education program. Children were excluded from the study, if they: (1) had a diagnosed mental disorder or mental retardation, and/or (2) had a condition that prevented them from participating in eight consecutive weeks of the Taming Worry Dragons. Children who did not participate, however, were permitted to receive the program. The parents and children had complete freedom to withdraw from the study at any point without consequences. Measures. The following measures were administered at pre-intervention and post-intervention. Multidimensional Anxiety Scale for Children. (MASC; March, 1997) is a self-report checklist for children, which measures physiological symptoms, worry, and inattentiveness associated with anxiety problems, and produces an overall anxiety score and a lie score (see Appendix D). The M A S C is a 39 item measure, in which respondents are asked to rate the frequency with which they experience particular symptoms on a four point Likert scale: 0 -never to 3 = always. The rating scale assesses several domains of anxiety that correspond more closely than other measures with DSM-IV (APA, 1994) classifications: physical symptoms (tense/restless and somatic subfactors), social anxiety (humiliation/rejection and public performance subfactors), harm avoidance (anxious coping and perfectionism subfactors), and separation/panic anxiety. The M A S C was standardized on 374 boys and girls in the United States in grades 4 to 12. March and colleagues (1997) report test-retest reliability of .79 in clinical samples and 45 .88 in school-based samples (March, Sullivan & Parker, 1999). The M A S C was highly correlated with the R C M A S (r = 0.63) but not with a measure of depression (r = 0.19) thus demonstrating good convergent and discriminate validity. In this study, the T-scores were collapsed, so that children who had a T-score of 56 or above were considered "At-Risk" students. Behaviour Assessment System for Children-Parent Rating Scales. (BASC-PRS; Reynolds, & Kamphaus, 1992) is an easily administered and quick to score parent measure that assesses a wide range of child behaviour (see Appendix E). The BASC-PRS measures positive (adaptive) as well as negative (clinical) dimensions of behaviour and personality. It has descriptors of behaviours that the parents rate in a four-choice response format: from "never" to "almost always," and consists of 138 questions, which require about 10 to 20 minutes to complete. The BASC-PRS has a test-retest reliability of .70 to .88 and the internal consistencies of the scales are in the middle .80s to low .90s. Types of scores produced are both percentile ranks and T- scores. This study only made use of the subsets for internalizing disorders; the instrument quantifies internalizing problems into the following subscales: anxiety, depression and somatization. Intervention Program In this study, a newly modified version of the manualized Taming Worry Dragons treatment protocol was used. This project involved the implementation of a newly adapted teacher's group-leader version of Taming Worry Dragons for the local school-system setting. The newly adapted version of Taming Worry Dragons (Group Facilitator Manual) is a linear, developmental classroom-formatted manual, which offers session-by-session outlines, agendas and objectives. 46 Taming Worry Dragons (Garland & Clark, 1995) is a CBT clinical program that teaches children to deal with anxiety using physiological, cognitive, and behavioural strategies. The group-based treatment program focuses on assisting children to learn and practice various tools (thought-stopping, distraction, physical exercise, changing self-talk) in order to cope with anxiety. Children are taught in an educational component what anxiety is and how it affects their bodies and their thoughts. The psycho-education component includes teaching children the connections between life experiences and anxious habits or negative cognitions, in order to increase self-awareness so that anxiety can be recognized earlier. A cognitive component helps the children realize how negative self-talk and catastrophizing perpetuates anxiety, as well as how to make more accurate and positive evaluations. The program helps to externalize the anxiety; it involves an imaginative re-conceptualization for the child to talk about worries separate from themselves. Procedure Information sheets (see Appendix B) outlining the aims and objectives of the study and describing the prevention program were sent home to all parents via each child in the grade three, four, five, six, and seven classes. Along with the information sheet, there was a consent form (see Appendix C) and the BASC-PRS assessment for the parents to fill out and return. The children returned the forms in a sealed envelope (provided with the package) and placed it in a bag in their classroom provided by the researcher. Data were also collected on the age and gender of participants via the consent form sent home to the parents. The teachers did not know which children were study participants. For the children whose parents did not consent to being part of the project, the Taming Worry Dragons program was applied 47 during class time; however, no data were analyzed on these children. None of the parents asked that their child not receive the intervention program in the classroom. Once the consent forms were collected, the pre-intervention screening using the M A S C took place. A l l children completed the M A S C questionnaire within class time. A l l students sat at their own desks while the set of standardized instructions were read (see Appendix F). The questionnaire was read aloud to the students, and they had the opportunity to ask questions about individual items but not to seek clarification about how they should respond. Students with reading disabilities were given extra time and reading support as needed. Students were informed that the questionnaires were confidential, and they were encouraged to ask any questions that they may have had. Those children, who were not part of the study, were informed that their data could not be used for the study and would be destroyed immediately upon arriving at the university. A l l participating teachers were part a of one-day training workshop covering the principles of anxiety, early intervention, and a step-by-step process of the newly revised Taming Worry Dragons program for classrooms. Dr. Sandra Clark, a clinical psychologist at B.C. Children's Hospital, and I facilitated this full day workshop. After the completion of the training workshop and the pre-intervention screenings with the M A S C and BASC-PRS, the two schools assigned as the treatment group (four classrooms) started implementation of the Taming Worry Dragons program. The teacher delivered the program to all the children in intact classrooms during the school day. The major advantage of universal implementation is the reduction of'false-negative' errors in the screening process (Barrett & Turner, 2001). While many screening tools often miss many children who are in need of help, a universal intervention allows everyone to gain the skills 48 necessary to deal with anxiety issues and may help to prevent the development of disorders later in life. Universal programs ensure children whose distress and symptoms have gone undetected will be helped. Conversely, to identify a group as At-Risk and pull them into a selected group may create a social stigma for them at a school. Therefore, the children all received the program with their teacher for eight one-hour sessions, which were held at the same time each week. Teaching of the program was part of each classroom's Personal Planning curriculum. The skills taught matched what is mandated, by the Province of BC and the Ministry of Education, for personal development in the areas of healthy living and mental well being (i.e. accessing sources of information and strategies to enhance their personal well-being, use strategies to share and express feelings and emotions, identify feelings, concepts of time management and problem solving methods) (B.C. Ministry of Education, 2005). A l l group leaders were required to adhere to the Group Leader's Manual protocol and each were asked to complete an intervention integrity questionnaire at the end of each session (see Appendix G). Each student received a workbook to complete during the sessions. None of the children withdrew from program participation in the classroom. Following the completion of the intervention program, all students (Taming Worry Dragons intervention participants and wait-list control) again completed the M A S C questionnaire, using the same standardized instructions as in the pre-screening and a letter was sent home to participating student's parents for them to complete the post-BASC-PRS. Participating students returned the completed BASC-PRS in a sealed envelope. After the post-intervention data were collected, the wait-list then received the Taming Worry Dragons 49 program. Upon completion of the Taming Worry Dragons program, the control group completed the M A S C again. After completion of the program, the parents of children who had scored in the clinical range on either the M A S C or BASC-PRS were informed of the elevated score by telephone, and a follow-up letter was sent; the letter included further information on anxiety, and suggested professionals for supporting their child. Throughout the study, all information was kept in a locked cabinet in a locked office at the University of British Columbia to ensure confidentiality; in addition, all students were identified only by a number assigned to them, and no information was shared with the participating schools' staff. Treatment Integrity. To determine the integrity of the intervention protocol, all facilitators were required to complete a checklist at the end of each session indicating the level of compliance with following the manual's session content. They were asked to respond on a Likert scale, providing five possible responses: "strongly disagree," "disagree," "neutral," "agree," and "strongly agree." Research Design The study used a randomized pretest-posttest control group design. The schools were randomly assigned to be either the treatment group or wait-list control group. The two groups' anxiety scores were compared at post-test, using pre-test scores as covariate; both children and parents' ratings were used. The independent variable in this study was the Taming Worry Dragons (Garland & Clark, 1995) program or wait-list controls. The dependent variables (assessment measures) were the scores on the M A S C and BASC-PRS measurements. Pre- and post-tests were administered at the beginning and end of the eight-week time period for all group subjects. This study looked at overall general changes in symptoms of anxiety and looked at the changes in symptoms of anxiety for the children who scored in the "at-risk" range, to determine the impact of the Taming Worry Dragons intervention. Data Analysis Data were analyzed, using the Statistical Package for the Social Sciences (SPSS). An alpha level of .05 was used for all statistical tests. To ensure there were no significant demographic differences across treatment conditions at pre-intervention, an initial analysis was conducted via independent samples /-tests comparing treatment condition and wait-list condition on age and gender, and M A S C and the BASC-PRS scores. As well, pre-intervention dependent measures (MASC for all children and BASC-PRS for all parents) were correlated to ascertain if there were any significant differences. Treatment Effects. A table is provided to show the means and standard deviations for the self-report measures at pre-intervention and post-intervention for both conditions. To determine the overall effectiveness of the Taming Worry Dragons (Garland & Clark, 1995) intervention program, in comparison to wait-list conditions, the results were analyzed in two stages: first, to determine within group change from pretest to posttest, a paired /-test for both M A S C and BASC- PRS was conducted on the treatment and wait-list control groups. The measurement of anxiety in children is often complicated by poor correspondence between children's self-reported anxiety ratings and ratings of their anxiety provided by their parents; therefore, to address this dilemma, I reported treatment-related changes separately for child and parent reports. 51 Second, to determine between group changes, the treatment groups' post scores were compared with the wait-list controls' post scores using an analysis of covariance (ANCOVA) with the pre-scores as covariate. The A N C O V A was conducted separately for each dependant variable (MASC and BASC-PRS). The same tests were then conducted for the children who scored in the At Risk and Clinical ranges in order to examine the percentage of children who were no longer At Risk or Clinical, at post-intervention. 52 Chapter Four Results In this chapter, all results will be presented including; (a) means and standard deviations to describe the data obtained, (b) chi squared test and /-tests to assess differences in each group's pre-scores, (c) correlations of parent-child anxiety ratings, (d) paired /-tests to test the within group changes at post-intervention; (e) A N C O V A s to test the significance of intervention effects, and (f) repeats of the /-test and A N C O V A s , looking at within group changes and between group differences for a subset of children classified as At Risk students. In addition, qualitative data derived from anonymous feedback forms from both the students and the teachers will be presented. The following analyses were performed to test the hypothesis that the CBT intervention would result in lower rates of self-reported and parent-reported anxiety symptoms at post-intervention, as measured by the M A S C and BASC-PRS, compared with participants in the wait-list group. Descriptive Data Demographic information shown in Table 1. Description of Means and Standard Deviations Table 2 displays the means and standard deviations for the intervention group and wait-list group on each dependent measure, at pre- and post-intervention. (At post-intervention, one child had to withdraw from participation due to moving.) 53 Table 1 Demographic Data Intervention Wait List N = 118 n 75 43 Sex of participants (N)boys 36 23 (N) Girls 39 20 Age M 9.35 10.47 7-years 3 0 8-years 13 0 9-years 31 0 10-years 14 23 11-years 12 20 12-years 2 0 Grades Grade Four's (N) 33 0 Grade Five (N) 12 23 Grade Six (N) 15 20 Grade Seven (N) 3 0 The subjective report of anxiety symptoms measured by the M A S C indicates that both the intervention group and the wait-list control group had pre-test means that, for the majority, were in the normal range on the M A S C . For this study, raw scores were converted to T-scores. The standard deviations ranged from 11.36 (intervention group) to 12.72 (wait list group). Post-test means indicated that both groups remained in the normal range for level of anxiety symptoms. Parent report of internalized problems measured by the BASC-PRS subscales for anxiety, depression and somatization, shows that the pre-test means for both groups were in the normal range on the Internalizing Problems composite. Pre-test standard deviation ranged from 11.53 to 13.73. Posttest means indicate that both groups remained in the normal range for internalizing problems, with standard deviations ranging from 10.80 (intervention group) 54 and 11.83 (wait-list group). Figure 1 shows the difference in pre- and post-test means for both groups on both measures. Table 2 Means and Standard Deviations of Dependent Measures Pre-intervention Post-intervention n M SD n M SD TWD Intervention Group MASC 74 51.01 11.36 74 48.85 10.79 BASC-PRS - Internalizing ; Composite 70 50.81 11.54 70 48.64 10.80 Wait-List Group MASC 43 48.00 12.70 42 45.09 14.09 BASC-PRS - Internalizing ; Composite 36 52.60 13.70 36 47.28 11.83 Note: MASC = Multidimensional Anxiety Scale for Children; BASC-PRS = Behavior Assessment System for Children - Parent Rating Scales. MASC „ „ _ , . „ BASC-PRS CB I Intervention Group M A S C „ , . , . „ BASC-PRS Wait List Group Figure 1. Change in anxiety scores. 55 Between Group Differences at Pre-intervention In order to assess initial comparability and to ensure that between-group differences were due to changes over the course of the intervention, Chi squared analyses and Independent samples /-tests were examined for pre-intervention differences in age and gender and all dependent variables. Chi squared analyses revealed that there were no significant differences for gender and age across groups: %2 (1, N = 118) = .329, p = .566. T-tests analyzing the dependent variables indicated no significant pre-test score differences between the intervention group and wait-list group on the M A S C , /(l 15) = 1.32, p = .187, the BASC-PRS Internalizing Problems composite, /(l 13) = -.735, p = .464, BASC depression subscale, /(l 13) = -.276, p = .783 or BASC somatization subscale, /( l 13) = .289, p = .773. The B A S C anxiety subscale scores, however, do indicate a between group difference, /(l 13) = -2.104, p = .038, with the wait-list group receiving higher scores on this scale. Parent-Child Correlation To assess i f the children's self report measure of anxiety on the M A S C correlated with the parent report of internalizing problems on the BASC-PRS, a Pearson's Correlation was conducted. The results of this statistical analysis indicted that the self-report M A S C moderately correlated with the BASC-PRS Internalizing Problems composite, r = .264, p = .004. Pre-Post Within Groups Paired t-tests In order to determine whether there were significant within group differences (p<.05) between pre- and post-test scores for either the intervention or wait-list groups, paired /-tests were compared for both measures. A paired /-test for the M A S C suggested that the self-report anxiety for the TWD intervention group was not significantly reduced from pre- to 56 post-intervention, /(72) = 1.87, p= .065. A paired /-test for the BASC-PRS Internalizing Problems composite, revealed a significant change for the intervention group, indicating that parent report of internalizing problems for children in the intervention group was reduced from pre to post-intervention, /(68) = 2.00, p = .049. For the wait-list group, a paired /-test for the M A S C revealed a significant within group change indicating that the wait-list group did reduce their level of self-reported anxiety symptoms from pre- to post-assessment, /(41) = 2.70, p= .01. A paired /-test for the BASC-PRS Internalizing Problems composite also revealed significant within group change, /(35) = 3.530, p = .001. The, wait-list group showed significantly fewer subjective symptoms of anxiety, as measured by the M A S C , and fewer parental ratings of internalizing problems (anxiety, depression and somatization symptoms) as measured by the BASC-PRS Internalizing Problems composite following the eight week waiting period. Table 3 shows the Paired /-test scores for within groups. In addition, effect size estimates were used as a supplement to the statistical significance testing in order to get a more complete picture of the magnitude of pre- to post-test changes within groups. Intervention effect sizes (Cohen's d) were calculated using the means from the M A S C and the BASC-PRS Internalizing Problems composite, as (Mpre -Mpost)/Sdpre (Kazis, Anderson & Mernan, 1998). Intervention effect size for the intervention group shows a modest improvement in anxiety symptoms (.19) for the M A S C . The wait-list group also reported a modest (.20) effect size for anxiety symptoms for the M A S C . Effect sizes for the BASC-PRS Internalizing Problems composite for the CBT group was (.19) and (.28) for the wait-list group, (see Table 3) 57 Table 3 Pre - Post Within Groups Paired t-tests Pre- Post- Effect size intervention intervention Sig. (Pre vs. Post) n M M t P d TWD Intervention Group M A S C 73 51.04 48.92 1.87 0.065 0.19 BASC-PRS Internalizing Composite 69 50.71 48.48 2.00 0.049 0.19 Wait-List Group M A S C 42 47.64 45.09 2.70 0.010 0.20 BASC-PRS Internalizing Composite 46 50.78 47.28 3.53 0.001 0.28 Note: MASC = Multidimensional Anxiety Scale for Children; BASC-PRS = Behavior Assessment System for Children - Parent Rating Scales. CBT Intervention Group versus Wait-list ANCOVA To compare the TWD intervention group with the wait-list control group, participants' scores were compared at post-intervention using two Analyses of Covariance (ANCOVA). An A N C O V A comparing the two groups (TWD intervention group and wait-list group) on M A S C scores at post, with pre-test scores on the M A S C as a covariate showed no significant difference between the two groups, F(l, 112) = .609, p = .437. An A N C O V A comparing TWD intervention group and wait-list group on the B A S C -PRS Internalizing Problems composite at post, with pre-test BASC-PRS scores as a covariate, also showed no significant difference between groups, F(\, 102) = .641, p = .425. At Risk Students This study examined the effectiveness of the intervention on the total population of the classes; the effects of the intervention on highly anxious children may have been overshadowed due to the majority of students with normal anxiety levels. The study also analyzed the effectiveness of the universal intervention on the subset of children scoring in the At Risk and Clinical range on the self-report measure of anxiety. Participants were divided into three groups: Normal, At Risk, or Clinical, based on the pre-intervention score on the M A S C . On the M A S C , the scores recommended by Dr. J. March (1997) were used as the measure of At Risk profile; a T-score between 56 and 70 represented that range in which students were considered to be At Risk for an anxiety disorder. T-scores above 70 represented students in the Clinical range. At pre-intervention, 22 participants (%) in the intervention group and 12 participants (%) in the wait-list group were classified as At Risk students. At post-intervention, 12 participants (%) in the intervention group were classified as At Risk students and 10 participants (%) in the wait-list group were classified as At Risk students. At post-intervention, four students from the TWD intervention group who were in the Normal range, moved into the At Risk range. The At Risk students in the intervention group had a mean of 63.75 (SD = 8.15) on the M A S C pre-test and a mean of 57.12 (SD = 7.45) at posttest. The At Risk students in the wait-list group had a mean of 64.92 (SD = 8.51) on the M A S C at pre-test and a mean of 64.61 (SD = 11.95) at post-test, (see Table 4) Table 4 At Risk Students Descriptive Statistics TWD Intervention Group M A S C BASC-PRS - Internalizing Composite Pre-intervention Post-intervention M SD M SD 22 63.75 8.15 57.12 7.45 22 55.27 9.80 54.55 12.52 Wait-List Group MASC 12 64.92 8.51 64.61 11.94 BASC-PRS - Internalizing Composite 9 58.11 16.87 56.11 16.81 Note: M A S C = Multidimensional Anxiety Scale for Children; B A S C - P R S = Behavior for Children - Parent Rating 59 In order to determine whether there were significant within group differences (p<.05) between pre- and post-test scores for the subset of At Risk students, in either the intervention or wait-list groups, paired /-tests were compared for both measures. For the At Risk students in the intervention group, a paired /-test for the M A S C revealed a significant change, indicating that the TWD intervention group did reduce their level of self-reported anxiety symptoms for pre to post-intervention, (/(21) = 2.823, p = .010). A paired /-test for the BASC-PRS Internalizing Problems composite did not reveal a significant change for the intervention group, indicating that parent report of internalizing problems for children in the intervention group was not reduced from pre- to post-intervention, (/(21) = .295, p = .771). For the At risk students in the wait-list group, a paired /-test for the M A S C did not reveal a significant within group change, indicating that the At Risk students in the wait-list group did not significantly reduce their level of self-reported anxiety symptoms from pre-post assessment, (/(10) = .121, p= .906). A paired /-test for the BASC-PRS Internalizing Problems composite also did not reveal significant within group change, (/(8) = .868, p = .411). (see Table 5 for paired /-test scores). In addition, effect size estimates were used as a supplement to the statistical significance testing in order to get a more complete picture of the magnitude of pre- to post-test changes within groups. The effect size for the At Risk students in the intervention group on the M A S C was .81, indicating a large improvement in self-report anxiety symptoms. For the At Risk students in the wait-list group, the effect size on the M A S C was .03. (see Table 5) To compare the TWD intervention group with the wait-list control group, the At Risk students' scores were compared at post-intervention using two Analyses of Covariance 60 (ANCOVA). An A N C O V A comparing the two groups (TWD intervention group and wait-list group) on M A S C scores at post, with pre-test scores on the M A S C as a covariate showed a significant difference between the two groups, with the intervention group reporting lower levels of anxiety at post-intervention (F(l, 30) = 4.673, p = .039). Table 5 Pre - Post Within Groups Paired t-tests for At Risk Students Pre- Post- Effect interventi interventio Sig. (Pre vs. n M M t p d_ TWD Group At Risk and Clinical M A S C 22 63.76 57.12 2.82 0.010 0.81 BASC-PRS Internalizing 22 55.27 54.55 0.29 0.771 0.07 Wait-List Group At Risk and Clinical M A S C 11 64.92 64.61 0.121 0.906 0.03 BASC-PRS Internalizing 9 58.11 56.11 0.868 0.411 0.12 Note: M A S C = Multidimensional Anxiety Scale for Children; BASC-PRS = Behavior Assessment System for Children -Parent Rating Scales. An A N C O V A comparing the At Risk students in the TWD intervention group and wait-list group on the BASC-PRS Internalizing Problems composite at post, with pre-test BASC-PRS scores as a covariate, showed no significant difference between groups, F(l, 28) = .024, p = .879. Qualitative Outcome Qualitative data were collected informally to assess the children and teacher responses to the implementation of the Taming Worry Dragons program. An anonymous nine-question survey relating to the enjoyment of the program, helpfulness of skills taught and implementation during class time was developed. Using a Likert-type scale, the students responded to seven questions on a 3-point Likert scale (a lot, sometimes and never) and two 61 open-ended questions, and the teachers responded to six questions on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree) and three open-ended questions. , One hundred and twenty one students responded to the survey (49 boys and 72 girls). In response to the question regarding the enjoyment of the program, 9 boys and 16 girls reported that they "liked the program a lot," while the majority of the students reported that they "sometimes" liked the program. When asked to describe the helpful aspects and skills of the program, comments from the student respondents included: the realization that they can calm themselves down and that "worry dragons" are not that scary after all, drawing their worry dragon and then imagining a trap for it, and that laughing can help keep worries away. A majority of the students reported that they enjoyed learning the relaxation techniques, especially deep breathing and imagining a peaceful place. A few students commented about the "power" of learning about positive thinking, for example: "when I g[o]t worried, I stopped the worry dragons and I took big deep breaths and sa[id], I can do it." In summary, most of the students were able to identify at least one of the skill they found helpful in the program, and a few commented that they are "less scared" now of things, as they have ways to calm themselves now. As one boy comments: "I learned just enough to stop the 'Worry Dragons' - not all the way, but I don't get scared all the time anymore." While not the majority, typical negative comments were about the amount of written work involved, and the program being boring due to the lack of games and creative ways to learn about the skills in the manual. In regards to session time, student's comments varied from too many sessions and sessions being too long, to needing more time to learn the tools. 62 Comments from the five teachers, when asked about the beneficial aspects of the program and ease of implementation included: reports on how the program appeared to help students see that others have anxiety (normalization), increase understanding of other people's feelings (empathy, especially in approaching children who are quite shy), comments on how the program provided a "common language" for everyone in the class to talk about worries. As a result, they found their classes talked about worries a lot more throughout the day, and commented on how the program appeared to increase students' comfort in talking about their feelings and concerns, and the increased disclosures from students about what makes them worry in their lives. Four out of the five teachers strongly agreed, or agreed, that they thought their students benefited from the program. Overall, the teachers reported a positive experience in teaching about the topic of anxiety. The most common negative comment by the teachers concerned the layout and the organization of the manual; one main objection was that too much preparation was involved. The teachers noted they were unable to complete most of the sessions in the time allotted and often felt "hurried," so many of the teachers had to do one session over several days. Rarely did a teacher complete a session in the time frame suggested; furthermore, most of the teachers adapted the sessions as they felt they needed to in order to enhance students' understanding of the lessons. The teachers also commented on the difficulty of getting students to complete the detective work due to parents' lack of understanding about the concept behind the homework, and the overall lack of information they had about the program. 63 Chapter Five Discussion This work was done as an initial attempt to implement and evaluate a locally developed CBT intervention for children (aged 7-12 years) with symptoms of anxiety. The aim of this study was to evaluate the effectiveness of a universal school-based intervention in a randomized control design, in reducing rates of anxiety symptoms in highly anxious individuals, through a comparison of students who received the CBT program and a wait-list control group. The hypothesis was that the CBT intervention would result in lower rates of self- and parent-reported anxiety symptoms in the highly anxious children, compared with participants in a wait-list group, at post-intervention. Results of the statistical analysis on the entire sample indicate that the manualized CBT intervention, which included relaxation training, cognitive restructuring, and behavioural components, did not show significant reduction in symptoms of anxiety within the general population of school aged children on either self- or parent report. As a group, the children who received the CBT intervention program did not emerge with significantly lower rates of anxiety symptoms at post-intervention as measured by either self-report or parent-report. The children in the wait-list condition, however, did report significantly lower mean scores on both the self- and parent-report measures. In an analysis of a subset of children, those students whose scores fell into the At Risk range (for developing an anxiety disorder or already symptomatic), the results indicate that the program significantly reduced symptoms in children who reported moderate to severe anxiety symptoms at pre-intervention (effect size = .8) The subset of At Risk children in the control condition did not change on self-report measure during this time. 64 This study's outcome results are a preliminary indication that in a general population of students the benefits of CBT intervention may not be easily detected; however, it can be seen from the positive results of the At Risk students that this program is consistent with those of previous studies, which support the effectiveness of a school-based intervention for the prevention of anxiety disorders (Dadds et al., 1997; Barrett & Turner, 2001; Lowry-Webster, et al. 2001). It may be expected there was no significant change on anxiety levels in the general population of the class, as the majority of the children would be expected to endorse normal levels of anxiety; i f there had been a decline in anxiety scores, then there would have been a valid cause for concern. The main concern is does teaching about anxiety and cognitive behavioral management skills to non-anxious children increase levels of anxiety? In the experimental condition, this was not the case, as evidenced by no statistical different in mean scores prior to and after the intervention for the majority population. The finding, however, of the control condition, where the group mean did significantly drop, confounds the above hypothesis. There was a noticeable difference in the ages between students in the treatment group and the wait-list group, however this age difference was not found to be significant. One might have argued that the younger students in the treatment group were not able to benefit from the cognitive component of the intervention, and it may be that the older wait-list group had a maturational effect. This remains unclear. There was also analysis of teacher variables or what other programs/skills the teachers in the wait-list condition were teaching the classroom during the waiting period. Perhaps the difference in change is the possibility that the children in the treatment group may have developed sensitivity to the instrument after receiving the anxiety program, thus increasing a better understanding of the self-report questions. Were these children in the CBT intervention group more able to report accurately on anxiety following the intervention program? This may be an area for future study. Lowry-Webster and colleagues (2001) were the first to demonstrate the effectiveness of a universal prevention trial, and the present study's results are consistent with their achievements in reducing anxiety rates in highly anxious students, when trained teachers implemented a CBT program within a universal classroom setting. Notable differences between my study and the Lowry-Webster one were the sample sizes used and the ages of the students involved; the Lowry-Webster study involved a larger sample size and used a much older population of students (ages 10-13 years). For highly anxious children, my study achieved the same effects. This was not the finding, however, for the general population in my study. Did they have a control condition? What happened to their controls? Speculation for why these studies varied in outcome perhaps is related to the CBT program used. In both Lowry-Webster and colleagues (2001) and Barrett and Turner (2001) studies, the FRIENDS for Children program was used. An active ingredient to reducing anxiety is exposure, which is incorporated into the FRIENDS program. In the present study, the Taming Worry Dragons program does include any parts in which students are gradually exposed to anxiety provoking situations. Another difference between the two programs is the amount of focus on cognitive reconstructing. Anxiety has a strong cognitive component, so the inclusion of cognitive techniques to challenge worry thoughts seems particularly salient. The FRIENDS program incorporates several sessions related to the importance of examining negative self-talk and to the relationship between thoughts, feelings and behavior. The Taming Worry Dragons manual, however, has only part of one session that focuses on changing negative self-talk to positive self-talk. It is also noted that the FRIENDS program is 66 run over ten weeks versus the eight for Taming Worry Dragons and offers the children booster sessions at both three and six months after having completed the program. There was positive qualitative support in this study, captured through participant responses. A majority of the participants responded that the skills taught in the program were easy to understand and learn, and were able to provide examples of the learned skills they found to benefit them the most. Some participants responded that they benefited from the personal power they gained to overcome their worries, and that they felt the program taught them that they can calm themselves down when they need to; participants also felt that they learned specific tools to help change their thoughts, and gained an increased sense of normality from hearing peers speak about concerns, worries and feelings similar to their own. These responses relate to the therapeutic factors of universality (the creation of feeling of normality) and interpersonal learning (through the sharing of their story of change) (Yalom, 1995). Some examples of the positive benefits the program provided for a few of the participants were: "the best thing I learned was how to speak in front of people without being nervous," and "I learned just enough to stop the 'Worry Dragons' - not all the way, but 1 don't get scared all the time anymore." Although the teachers attended a day of training, the question arises of whether this training length was adequate enough for learning and understanding the program components. While it was not an aim of the study to examine the effectiveness of teachers in the implementation of the program, teacher facilitation does have an impact upon the effectiveness of the program. Because of the lack of time for training, only the afternoon portion of the training day focused on facilitation of the Taming Worry Dragons program, and there was limited teaching regarding the importance of the cognitive component. This 67 aspect of the program could be solved in future projects by simply having more than one researcher on the team; this would allow for more focused teacher training, over a longer period of time, and would also allow for more follow-up with the teachers after the training day. Even if more time and resources were available for this study, universal intervention is still suggested because of classroom dynamics; teachers and researchers don't always know which students belong to the high-risk group, so they would potentially be missed i f pullout groups were used. Also, stigmatization of children in pullout groups might occur within the classroom. With more time and resources, pro-social measures of change could have been taken to show changes in the population of students with normal anxiety levels, in order to make the program even more beneficial to all. The Taming Worry Dragons program offers many benefits to the entire population of students including stress management skills, problem-solving skills, empathy, time management, and enhancement of self-expression. Limitations Resources affected the measures taken to obtain post-intervention reports; there was a need for a reliance on only self- and parent report measures, and there was no control over which parent completed the first and then the second assessment. Male and female parents report differently on assessments of child anxiety. The use of multiple informants or other ways to identify improvements is important. Self-reports may not be an accurate reflection of change; it may have been beneficial to have a teacher's report of how children changed in the classroom or behavioural assessment (for example, increases in the students' levels of participation in class or activities, or increases in the quality of personal interactions). A regular meeting with the teachers to address questions and concerns, and parent conferences 68 would have contributed to the even more positive and accurate reflection of the program's achievements. There was also a limitation in terms of controlling for external variables. This study did not screen for children with other mental health issues (ADHD, depression or conduct disorder), which may have impacted detection of the program anxiety symptoms. The small sample size was a limiting factor of the study. Generalization was not a goal of this study; however, because a small sample of convenience was drawn, we cannot generalize to the general population. A related limitation with the sample used is the lack of report on both the social-economic and cultural variables of the population. Studies of more ethnically and economically diverse samples would offer generalizability. The study was also limited by the lack of a follow up. Weisz and colleagues (1995) noted that less robust treatment outcomes are often linked to post-treatment assessments that were administered too soon after treatment, therefore, a six-month follow-up may have been more indicative of the status of the children in the groups. There is a definite possibility that the program may have increased the children's understanding of their anxiety and what behaviours they would engage in afterwards; as a result, a second assessment may have been a more accurate reflection of the results. Also as noted by Donovan and Spence (2000), "...universal studies, by definition, target an entire population including those not at risk, [so] they require large sample sizes and long-term follow-up to enable discernable differences between groups" (p. 521). The final limitations to this project were time and resources; a lack of sufficient resources meant limitations to the study that may have affected the results. For example, within the school setting, the teacher-training day had to be paid for by the author personally; 69 this meant that there was a shortage of time (because of the expense) allocated for this portion of the project. With more resources available, there could have been more time devoted to teacher training as well as parent contact meetings. Future Research The breadth of the effects of CBT intervention is unlikely to be known unless the study is replicated with a larger sample size and the use of follow-up assessments. Long-term benefits of the Taming Worry Dragons program remain to be demonstrated sufficiently; therefore, future research should incorporate several follow-up periods. An evaluation of teacher report measures, behavioural observations, and pro-social measures within the classroom is also suggested, to fulfill a need for further support towards the effectiveness of the intervention. Finally, the possibility of incorporating a parental component needs to be explored to determine how parental involvement might be used to enhance intervention effectiveness. It would seem that the level of parent interest and support would directly affect the results achieved by this type of program, particularly because there is a homework component for the children. Because anxiety has a strong cognitive component, there may be a need for a more focused approach to this portion of the training. This manual has only one session focusing on changing negative self-talk to positive self-talk, and little training for teachers that focuses on the importance of cognitions. This aspect of the program could be solved in future projects by simply having more than one researcher on the team; this would allow for more focused training, over a longer period of time, for the teachers involved. There may also be a need to add more sessions, and lengthen the time of each session. 70 Within the classroom itself, a more consistent and timely approach would be more conducive for the children. More complete training practices would lead to less prep time for the teachers, and would positively affect their enthusiasm for the project; this, in addition to a higher likelihood of teacher understanding of what each session involves, would contribute to an ability to implement a consistent session time for students. A final future recommendation would involve a considerable budget increase. This would allow for more attractive student and teacher materials, and would also affect the ability to use a larger sample size. More funding would also support a more in depth look into the pro-social aspect of this program, particularly for the normal-range children. Conclusion Despite the mixed results of this study, continued research in the area of primary prevention is absolutely encouraged. This method of intervention overcomes many of the barriers associated with the treatment of children who have already developed an anxiety disorder, such as cost, long waiting periods, and the risk of developing additional mental health issues. However, due to results that demonstrate positive change for the subset of At Risk students, it may be that the program is beneficial for selective/targeted groups of highly anxious children. The purpose of this study was to determine if the Taming Worry Dragons program, a CBT intervention program, would be effective in reducing anxiety levels in highly anxious school-aged children, in a classroom setting. The present findings demonstrate that the Taming Worry Dragons was effective in reducing levels of anxiety in highly anxious children when delivered universally to a school population. There are many encouraging responses and interested parties, which pushes for further research into CBT intervention. A 71 subset of At Risk students benefited from the program, and this study has provided a number of useful implications for future research. 72 REFERENCES Albano, A. M . , Chorpita, B., & Barlow, D. (2003). Childhood anxiety disorders. In E. Mash & R. Barkley (Eds.), Childpsychopathology (2 n d ed.) (pp. 279-329). New York: Gilford Press. Albano, A. M . , & Morris, T. (1998). Childhood anxiety, obsessive-compulsive disorder, and depression. In J.J. Plaud & G.H. 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Silverman, W., Kurtines, W., Ginsburg, G., Weems, C , Lumpkin, P., & Carmichael, D.H. (1999). Treating anxiety disorders in children with group cognitive-behavioural therapy: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67(6), 995-1003. Southam-Gerow, M . (2001). Generalized anxiety disorder. In C. Essau & F. Petermann (Eds.), Anxiety disorders in children and adolescents: Epidemiology, risk factors and treatment (pp. 219-260). United Kingdom: Biddies. Stock, S., Werry, J., & McClellan, J. (2001). Pharmacological treatment of paediatric anxiety. In W. Silverman & P. Treffers (Eds.), Anxiety disorders in children and adolescents: research, assessment and intervention (pp. 335-367). Cambridge; U.K: Cambridge University. Sweeny, L., & Rapee, M . (2001). Social phobia. In C. Essau & F. Petermann (Eds.), Anxiety disorders in children and adolescents: Epidemiology, risk factors and treatment (pp. 163-192) United Kingdom: Biddies. Turner, S., Beidel, D., Roberson-Nay, R., & Tervo, K. (2003). Parenting behaviours in parents with anxiety disorder. Behaviour Research and Therapy, 41, 541-554. Waddell, C , & Shepherd, C. (2002). Prevalence of mental disorders in children and youth. Vancouver, British Columbia: Mental Health Evaluation and Community Consultation Unit, University of British Columbia. Retrieved June 27, 2003, from http://www7.mcf.gov.ca/mental_health/mh_pulications/02a cymh.pdf Walker, J. (2000). Proposal for development of a specialty service within the anxiety disorders program (draft copy). Presentation to the Department of Clinical Health Psychology in Manitoba. Walkup, J., Labellarte, M . , & Ginsburg, G. (2002). The pharmacological treatment of childhood anxiety disorders. International Review of Psychiatry, 14,135-142. Weems, C , Berman, S., Silverman, W., & Saavedra, L. (2001). Cognitive errors in youth with anxiety disorders: The linkages between negative cognitive errors and anxious symptoms. Cognitive Therapy and Research, 25 (5), 559-575. Weisz J.R., Donenberg, G. R., Han, S., Weiss, R. (1995). Bridging the gap between laboratory and clinic in child and adolescent psychotherapy. Journal of Clinical Child Psychology, 63, 688-701. Woodward, L. (2001). Life course outcomes of young people with anxiety disorders in adolescence. Journal of the American Academy of child and Adolescent Psychiatry, 4 (9), 1086-1093. 83 Yalom, ID. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books, Inc. 84 APPENDIX A Letter to Educators Dear Educators, I am a student in the Masters program of Counselling Psychology at the University of British Columbia carrying out a study entitled " A Universal Prevention Program for Anxiety Symptoms in School Aged Children: Taming Worry Dragons" The project is concerned with teaching children valuable skills necessary for managing stress and worry and to reduce the levels of anxiety symptoms in those students who are more anxiety prone so they may be less likely to develop an anxiety disorder. Anxiety is a common condition and as many of you know, anxiety disorders are the most common emotional, mental, and behavioral problem for adults and children. Anxiety is a common condition, which usually serves as a means of protection and can often enhance one's performance in stressful situations. However, for some students anxiety interferes with normal life experiences and interferes with their success on tests, on studying, and on their attention in class. Anxiety can lead to people avoiding things, events, fearing new situations, and refusing to participate in routine activities. Children with anxiety have constant worries about things before they happen, school performance, friends or sports, and fears of embarrassment or making mistakes. Research indicates that up to 21% of children can have a diagnosable level of anxiety (Costello et al., 1988). A l l children have stress and all children feel anxious at times, but they may not know how to manage their feelings of anxiety and adults may not know how to help them manage. Research has demonstrated that intervening early with prevention programs can be extremely successful in helping children overcome these fears, worries and anxieties. If anxiety disorders are left untreated, they may pose difficulties throughout life. This project will ascertain the efficacy of a brief cognitive-behavioral treatment program (Taming Worry Dragons) delivered by classroom teachers. The main goal of the project is to reduce anxiety disorder symptoms in public school children with the long term objective having anxiety disordered behavior and thinking patterns reduced in order to prevent the onset of an anxiety disorder. School personnel are often the first to observe unusual behaviors in children, school personnel can be trained to recognize and ameliorate this childhood distress. This project plans to train interested school personnel (classroom teachers, school counsellors, school nurses, etc) as group facilitators to deliver the cognitive behavioral curriculum, Taming Worry Dragons. Research Plan: A l l participating teachers and other school personnel will attend a one-day training during the school day. The project will pay for the costs associated with this day training. The purpose of this training to: (1) Increase understanding of anxiety disorders, (2) Identify anxiety disordered behavior in children, and (3) Train school personnel in implementation of the Taming Worry Dragons curriculum. Letters for parental consent will be sent home with each child via the classroom and returned to the classroom in a sealed envelope. A l l grade five and six children in the participating Langley elementary schools will be screened by the researcher for anxiety symptoms using the Multidimensional Anxiety Screen for Children (MASC). Scores will be confidential, and 86 APPENDIX B Parent Information Package Dear Parent or Guardian: This form is to request permission for your son/daughter to participate in an exciting research project that I am conducting as my thesis through the University of British Columbia. The project is entitled " A Universal Prevention Program for Anxiety Symptoms in School Children: Taming Worry Dragons" and is concerned with teaching children valuable skills necessary for managing stress and worry. Listed below are several aspects of this project that you need to know: Investigator: Christina Short, Counselling Psychology Dept. at U B C Supervisor: Dr. Lynn Miller, Ph. D., Counselling Psychology Dept. at the University of British Columbia. (604) 822-8321 Purpose: The purpose of this study is to reduce the rate of anxiety symptoms and the later development of anxiety disorders in children. Anxiety is a common condition, which usually serves as a means of protection and can often enhance one's performance in stressful situations. However, for some students anxiety interferes with normal life experiences and interferes with their success on tests, on studying, and on their attention in class. Anxiety can lead to people avoiding things, events, fearing new situations, and refusing to participate in routine activities. A l l children have stress and all children feel anxious at times, but they may not know how to mange their feelings of anxiety. Research has demonstrated that intervening early with prevention programs can be extremely successful in helping children overcome these fears, worries and anxieties. If anxiety disorders are left untreated, they may pose difficulties throughout life. Your child will be participating in a UBC and B.C. Children's Hospital research project, support by the Langley School District, using an anxiety prevention curriculum for all grades four, five and six children. Study Procedures: The study involves all students in grades five and six participating. Their teacher will instruct them in a group activity called, Taming Worry Dragons, in the classroom at the elementary school for one hour, once per week for eight consecutive weeks (total time 8 hours). Taming Worry Dragons is a brief curriculum developed for teachers and counsellors to use in the schools. It is positive program, which teaches children various "worry-taming" tools to enhance a child's confidence in their ability to cope with worries and anxiety. 88 by your son/daughter along with your completed BASC questionnaire in the envelope to their classroom. This stapled package is for you to keep as your copy. Thank you very much for considering this request. Sincerely, Christina Short Masters of Arts Student Department of Education/ Counselling Psychology Please keep this stapled copy for your records! 89 Consent Form A Universal Prevention Program for Anxiety Symptoms in School Children: Taming Worry Dragons Consent: I have read and understand the attached letter regarding the study entitled " A Universal Prevention Program for Anxiety Symptoms in School Children: Taming Worry Dragon." I have also kept the stapled copy of both the letter describing the study and this permission slip for my own records. I understand that my participation in the study, and that of my child's is entirely voluntary and that I may refuse to participate or withdraw from the study at any time without jeopardy to my child's class standing or any other school function. Yes, my son/daughter has my permission to participate in the study. No, my son/daughter does not have my permission to participate in the study. Parent's Signature Date: Parent Name (please print): Home telephone number: Child's Name: Age: Teacher's Name: Grade: School: Ethnicity: Home Language: Please keep this stapled copy for your records! 90 APPENDIX C Consent Forms A Universal Prevention Program for Anxiety Symptoms in School Children: Taming Worry Dragons Consent: I have read and understand the attached letter regarding the study entitled " A Universal Prevention Program for Anxiety Symptoms in School Children: Taming Worry Dragon." I have also kept the stapled copy of both the letter describing the study and this permission slip for my own records. I understand that my participation in the study, and that of my child's is entirely voluntary and that I may refuse to participate or withdraw from the study at any time without jeopardy to my child's class standing or any other school function. Yes, my son/daughter has my permission to participate in the study. No, my son/daughter does not have my permission to participate in the study. Parent's Signature Date: Parent Name (please print): Home telephone number: Child's Name: Age: Teacher's Name: Grade: School: Ethnicity: Home Language: (Please complete this consent form, the enclose B A S C questionnaire, and place in the enclosed envelope. Please seal, with your child's teacher name on the outside. Return to your teacher. A l l response will be held confidential.) 92 APPENDIX D Sample Items from M A S C Assessment I feel tense or uptight I get scared when my parents go away I have trouble getting my breath I try to stay near my mom or dad I worry about getting called on in class I'm jumpy I keep the light on at night I try to do things other people will like I feel restless and on edge I worry about doing something stupid or embarrassing I feel sick to my stomach I check to make sure things are safe My hands feel sweaty or cold Never Rarely Sometimes Often true true true true about about about me about me me me 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 APPENDIX E Sample Items from BASC-PRS Assessment 93 Behavior Behavior Behavior never sometimes often occurs occurs occurs Worries Complains of shortness of breath Wets bed Complains of dizziness Worries about what parents Complains of pain Gets upset when plans change Says, "I get nervous during tests" or "Tests make me nervous." Is shy with other children Worries about what teachers think Says, "I'm afraid I will make a mistake." Has difficulty breathing Sleeps with parents N N N N N N N N N N N N N S S S s s s s s s s s s o o o o o o o o o o o o o Behavior almost always occurs A A A A A A A A A A A A 94 APPENDIX F Standardize Instructions for M A S C Instructions for completing the MASC Protocol What to bring when going collect the data: 1. The script 2. Packet of M A S C ' s (need a few extra just in case child makes a mistake) 3. Extra pencils 4. Class list to mark absent children Sequence of Events: 1. Ask the teacher if there are any students absent and i f so what day or time it would be suitable to come back for completing the absentee measures. Mark these students absent and keep the names with the completed protocols. 2. Ask the teachers if there are any students that are likely to need extra assistance (ESL/learning difficulties). WHEN ASSISTING STUDENS, IT IS R E A L L Y IMPORTANT TO O N L Y C L A R I F Y THEIR QUESTIONS - CANNOT " C O A C H " T H E M OR SUGGEST POSSIBLE REPONSES. 3. Ask the teacher if it is OK to write on the board; if so, write out the top of the M A S C identifying information (name, age, gender, grade etc.) to go through with the children and write out the first two example questions on the M A S C . 4. Ask the teacher what the children should do who finish the measures early 5. Get the children to make sure they are away from friends; space in between them. 6. Introduction of the reason for the measure. 7. Information about completing the measures. 8. Administration and collection of the measure. 9. Put all the measures in a large envelop and seal it in front of the class. Write classroom teacher and school on the envelope. Introduction to the Students: "Hello! My name is Christina Short, and I will be helping your teacher, Mr/Mrs/Ms. _ . I am a student from the University of British Columbia, in Vancouver, and I am doing research on a new program for school kids. Anxiety is a big word for feeling worried or sad or nervous. Many people think that kids sometimes feel quite anxious. You can feel worried about different things like doing well in school, your friendships, or things at home. This can be a very icky feeling for anyone. There is a program that we think will help all kids feel better. I am here because I would like your help to see if this program works. The program is quite simple. Your teacher will give you one lesson each week in you own class. The great news about this is that there are no tests! 95 This program is voluntary. This means you do not have to take part if you do not want to. Your parents know about this program too. Any questions? Before you start to complete this questionnaire there are a few things that I would like to tell you: This is not a test. There are no right or wrong answers and you will not get any marks for completing this, but you must think about the questions very seriously and answer them as truthful as you can. You should circle the answer that is most like you. I also want you to know that your answers will be completely private - no one else other than myself and my research team at U B C will see your answers. Not your mom, not your dad, not your teacher and not your friends. So you should not let anyone else see your answers. Once you start completing the questionnaires there should be no talking, as this is a very serious thing that I would like you to do. I want you to tell me how you feel." Handout the questionnaires & Completion: "I am now going hand out the questionnaires. Please do not start to complete the questionnaires until I tell you. I am going to go through the top part with you and give you a few examples. I will then read the each question aloud to you. If you have a question just put up your hand." "Ok! Everyone put your full name at the top. (Demonstrate on the board; stress first and last name needed). Let me know how old you are, what grade you are in, whether you are a boy or a girl (demonstrate circling female on the board) and what the date is today." Then read the description at the top of the questionnaire, and demonstrate how to answer the questions that are already on the board. Ask if any one has any questions. "OK! Boys and girls we are now going to complete the questionnaire. I will read the questions out to you and you will circles which answer is most like you, just like I did on the board. Do not forget that i f you need any help put up your hand and I will come and help 96 you. There are some questions on the back of the form that we will need to complete so when I have finished reading all the questions on the front I will tell you to turn it over. Remember not to talk to your friends about this because we only want to know how you feel. Administration of the MASC: Read each question slowly and carefully. Walk around the room ensuring that all the children are completing the measure correctly and answering any questions. It is important to ensure that the children do not skip any of the questions. It may be helpful to have to children take out their rulers and place it under each of the questions in turn to ensure they circle the right number for each question. Also have to make sure the children turned over the page and completed the second sections of questions. If children completed the form before others, remind these children to take out a book to read or finish homework until all the children have finished. Completion of the MASC: Collect all the M A S C ' s and put them into a large envelope and seal it. "Thank you boys and girls for helping me with the study. I will come back after you have completed the Taming Worry Dragons program to do the questionnaire again." Thank the teacher and leave the classroom. Make sure the name of the school, the class grade and teacher's name is on the envelope. Remember to include the names of the absent students and the time when it will be most appropriate to come back. 97 APPENDIX G Teachers Integrity Questionnaire Taming Worry Dragons Prevention Project Sess ion Evaluation Form Date: In order to maintain treatment integrity, it is important to following each session as laid out in the manual. I would like your feedback about aspects of each session. Please take a few minutes to complete this form. Your responses will be kept confidential. Thank you fo r your assistance Session # S t r o n g l y D i s a g r e e N e u t r a l A g r e e S t r o n g l y D i s a g r e e A g r e e a) The session material is well presented 1 2 3 4 5 b) The activities are easy to follow and teach to the class 1 2 3 4 5 c) I was able to complete the full session 1 2 3 4 5 d) The session is relevant to my Grade of students. 1 2 3 4 5 e) I did not need to make any changes to the session 1 2 3 4 5 to help my students understand the concepts I f any changes/alterations to the session were made, please give some details. Any suggestions? 98 APPENDIX H Taming Worry Dragons Anxiety Prevention Project Teacher Participant Evaluation Form I would like your feedback about aspects of the research project you have been participating in over this part term. You r responses will help add a qualitative p iece to me thesis, as well, it will be great direct feedback for others who may use this program within the community. You r responses will be kept confidential! Thank you for your ass is tance! S t r o n g l y D i s a g r e e D i s a g r e e N e u t r a l A g r e e S t r o n g l y A g r e e 1) The T W D facilitator manual was well laid out and useful. 1 2 3 4 5 2) The TWD program itself was easy to implement. 1 2 3 4 5 3) The TWD child workbooks were use in helping to teach each taming skill. 1 2 3 4 5 4) The children enjoyed doing the T W D program. 1 2 3 4 5 5) I enjoyed delivering the T W D program. 1 2 3 4 5 6) I think the children in my class benefited from the T W D program. 1 2 3 4 5 What did you like most about the Taming Worry Dragons program? Wha t do you think should be changed about the Taming Worry Dragons program? A n y other comments? 99 APPENDIX I Student Participation Evaluation Form Hey! Tell Us What You Think! We would like to know what you thought about Taming Worry Dragons program! This survey is anonymous, so we don't want you to put your name on it. Please circle one answer fo r each question. M y age: W h a t language do y o u s p e a k a t home m o s t l y ? F o r t h e n e x t q u e s t i o n s , p l ea se c i r c l e t h e f a c e t h a t y o u t h i n k b e s t d e s c r i b e s w h a t y o u t h i n k a b o u t t h e T a m i n g W o r r y D r a g o n s program. . . I am'- A boy A g i r l ( c i r c l e one) a lot sometimes = never 1. I liked the T W D program 2.1 know how to use T W D tools 3 .1 can calm myself down when I am worried 4 . 1 liked the T W D workbook 5 .1 would like to do T W D in school again 6. The skil ls taught to learn how to tame Wor ry Dragons were easy to understand and learn 7. I t was helpful having the program taught in out classroom during school time 100 P l ea se t u r n me over. . . What was the best thing you learned in the T W D program? What do you think should be changed about the T W D program? T h a n k y o u f o r he lp ing us o u t by f i l l i n g o u t t h i s fo rm! ! 

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