Employment, Social Affairs & Inclusion

Classroom-based cognitive behaviour therapy to prevent anxiety (FRIENDS programme)

Evidence level:
 
Evidence of effectiveness:
? - 0 + ++
Transferability:
? - 0 + ++
Enduring impact:
? - 0 +

Overview

The FRIENDS protocol is designed to be delivered in both clinical and educational settings by teachers, psychologists, and allied health professionals. The programme is a manualised cognitive behaviour therapy (CBT) intervention. It is based on the principles of CBT and aims to help children develop skills to counter the cognitive, emotional, and behavioural aspects of anxiety. It seeks to teach children to develop emotional awareness and regulation skills, identify and replace cognitions that increase anxiety with more balanced and functional ways of thinking, and to develop problem-solving skills to confront and cope with situations and events that provoke anxiety.

Practice Category

Helping Vulnerable Children, Facilitating Positive Transitions to Adulthood

Recommendation pillar

  • Access to affordable quality services
    • ​​​Improve the responsiveness of health systems to address the needs of disadvantaged children,
    • Improve education systems’ impact on equal opportunities,
  • Children's right to participate
    • ​Put in place mechanisms that promote children’s participation in decision making that affect their lives

Countries that have implemented practice

United Kingdom

Age groups

Middle Childhood (age 6 to 12)

Target groups

Children

Years in operation

2011 - Still operating

Scope of practice

Regional level, National level, Local level

Type of organisation implementing practice

Other Private Organization

The FRIENDS protocol is designed to be delivered in both clinical and educational settings by teachers, psychologists, and allied health professionals. For any use of the Friends programs, individuals, schools, government entities and/or organisation have to become Licensed Partners. In the case of this RCT evaluation, the sessions were delivered either by trained health facilitators working alongside the class teacher, or by a teacher / member of the school staff.

Rationale/theory of practice

The programme is a manualised cognitive behaviour therapy (CBT) intervention. It is based on the principles of CBT and aims to help children develop skills to counter the cognitive, emotional, and behavioural aspects of anxiety. It seeks to teach children to develop emotional awareness and regulation skills, identify and replace cognitions that increase anxiety with more balanced and functional ways of thinking, and to develop problem-solving skills to confront and cope with situations and events that provoke anxiety. Skills covered are represented in the letters of the acronym FRIENDS, and the overall the content is as follows: F= Feelings: This stage of the program focuses on building participants’ skills in recognising and responding to their own feelings as well as the feelings of others. R= Remember to Relax, Have Quiet time: The second stage of the program involves learning about physiological signs of emotions. I= I can do it. I can try my best: In the third stage, participants are introduced to attention training and the cognitive model. E= Explore solutions and Coping Step Plans: Overall this stage focuses on learning coping skills and plans to overcome challenging. N = Now reward yourself: This stage involves teaching participants the importance of self-rewarding. D= Don’t forget to practice: Skills are most effective when practised every day and therefore the goal of this stage is to encourage participants to continue using the skills after the program is completed. S= Smile! And Stay calm: The final stage of the program is the relapse prevention phase.

Mode of delivery

Group sessions, Face-to-face

The practice consisted of weekly face-to-face session delivered to whole classes of children. Children had their own workbooks, and group leaders had a detailed session plan specifying key learning points, objectives and core activities for each session. In the evaluation of FRIENDS reported below, there were two modes of delivery. While both were delivered face-to-face, the health care–led FRIENDS sessions were led by two trained facilitators working alongside the class teacher. The school-led FRIENDS sessions were led by a trained teacher or a member of the school staff and were supported by two facilitators. All facilitators had at least an undergraduate university degree in a relevant discipline, an appropriate professional background and/or experience in working with children and young people.

Delivery dosage

Frequency: Weekly, Duration: 1 hour sessions

Interventions were delivered in the academic year September, 2011, to July, 2012. The intervention trialled in this evaluation consisted of nine, 60 minutes weekly sessions delivered to whole classes of children.

Location of practice

School based

The practice was implemented in state-funded junior schools in three Local Education Authorities in southwest England.

Evidence of effectiveness

Practice has been evaluated

The aim of the trial was to investigate whether children can learn skills during their Personal, Social and Health Education (PSHE) lessons that will help them to cope with worries and anxious feelings. Specifically, the evaluation assessed the effectiveness of a classroom-based anxiety prevention programme called “FRIENDS”. The programme assists children in learning important skills and techniques that help them to cope with and manage anxiety and emotional distress through the application of learned coping and problem solving skills. The trial compared three types of intervention delivered in different schools in the UK to children aged 9–10 years. In 14 schools (449 children in total) the sessions of the FRIENDS programme were led and delivered by trained health professionals. In other different 14 schools (436 children in total) the sessions of the FRIENDS programme were led and delivered by a teacher or member of the school. Lastly, in 12 schools (401 children in total) the usual school provision of PSHE was delivered. In order to compare the three interventions, children were asked to self-complete a questionnaire at the beginning of the intervention, after 6 and 12 months. The primary outcome measured by the questionnaire was symptoms of anxiety and low mood as established by the Revised Child Anxiety and Depression scale (RCADS 30). Secondary outcomes assessed worry, self-worth and acceptance, extent of bullying, and life satisfaction. Parents and teachers also completed some questionnaires. The results indicate that children that took part in the FRIENDS programme delivered by health professionals reported lower anxiety symptoms compared to the children that participated in the FRIENDS programme delivered by school members, and compared to children that did not receive the FRIENDS programme but usual school provision. The results therefore indicate that anxiety programmes delivered in schools may reduce anxiety symptoms. However, the same programme can have different effects depending on who delivers it: the results of the trial show that the FRIENDS programme was effective only when was delivered by health trained professionals.

Evaluation

Stallard, Paul, Elena Skryabina, Gordon Taylor, Rhiannon Phillips, Harry Daniels, Rob Anderson, and Neil Simpson. "Classroom-based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES)." The Lancet Psychiatry 1, no. 3 (2014): 185-192. Available at: http://www.sciencedirect.com/science/article/pii/S2215036614702445

Relevant information regarding timing of evaluation or measurement of outcomes

The evaluation consisted in a three-group parallel cluster randomised controlled trial conducted between September 2011, and July 2012, with school as the unit of allocation and individual participants as the unit of analysis. A project information sheet and trial enrolment form was sent to all primary schools in Bath and northeast Somerset, Swindon Borough, and Wiltshire within a 50 mile radius of the University of Bath, UK (n=268). 45 schools were enrolled. 41 consented to participate and were randomly assigned: 14 (n=497 children) to school-led FRIENDS, 14 (n=509) to health-led FRIENDS and 12 (n=442) to usual school provision. One school from usual school provision withdrew before baseline assessments were undertaken. The remaining 40 schools were representative of the UK in terms of academic attainment according to Department of Education performance tables (i.e., the percentage of children achieving key stage 2 level 4 in maths and English).  Of the 1448 eligible participants, 1362 (94%) consented to participate in the study, of whom 1339 (98%) completed baseline assessments. Primary outcome data were collected at 12 months from 1257 (92%) of the children who completed baseline assessments (449 [92%] in the health-led group, 436 [92%] in school-led group, and 372 [93%] in the usual school provision).

Child outcomes were collected during class time with self-completed questionnaires administered by researchers at baseline, 6 months, and 12 months. The primary outcome was symptoms of anxiety and low mood 12 months after baseline as established by the Revised Child Anxiety and Depression scale (RCADS 30). Secondary outcomes assessed worry, self-worth and acceptance, extent of bullying, and life satisfaction. Parents completed a behavioural screening questionnaire and the parent version of the Revised Child Anxiety and Depression Scale at baseline, 6 months, and 12 months. Class teachers completed the impact rating of the Strengths and Difficulties Questionnaire (SDQ) for all children in their class at all three assessment points to assess the presence of an emotional or behavioural problem, chronicity, distress, social impairment, and burden.

The table below reports the analysis of the primary outcome (child-completed RCADS) for all children at 12 months for health-led FRIENDS and school-led FRIENDS versus usual schools provisions (PSHE education).

 

Summary of Results for Evaluation 1

 

            Adjusted difference (95% CI) at 12 months for:

Outcome

Health-led FRIENDS vs usual school provision

Health-led FRIENDS vs school-led FRIENDS

School-led FRIENDS vs usual school provision

RCADS

(Revised Child Anxiety and Depression Scale)

-2.66 points

95% CI (-5.22; -0.09)

-3.91 points

95% CI (-6.48; -1.35)

1.28 points

95% CI (-1.30; 3.87)

Transferability

The practice has been evaluated in more than one population and found positive effects in at least two of these populations

Enduring impact

The study does not meet the EPIC criteria for enduring impact, which requires at least a 2-year follow up with at least one significant result. The study has not had a follow-up study to re-assess the results nor is it known if any is planned.

Issues to consider

There are few issues to consider, which are explicitly recognized in the article:

  • The study relied on self-report measures and did not undertake any diagnostic interviews;
  • Although the regional cohort included a representative sample of UK schools on several key dimensions, the group was less socially disadvantaged and had more white British participants than did the average UK state school;
  • The study did not directly assess how the intervention was delivered;
  • The study is unable to establish whether the improvements reported would be sustained over time.

There is one methodological weakness that is not recognized by the authors. The conclusion that FRIENDS programme is significantly more effective when delivered by health rather than educational professionals, can also result from the fact that health professionals delivering the intervention were new to the schools while the teachers were members of the school staff (novelty effect, also referred to as the Hawthorne effect).

Practice Materials

Practice materials available but not accessible online

To deliver FRIENDS programmes, individuals need a license. A license can be obtained through a FRIENDS provider by attending a one day training which costs around £250 (in the UK) and includes a set of books (1 facilitator manual + 1 workbook). Online trainings are also available.

Available resources

Barrett P. Friends for life: group leaders manual for children. Bowen Hills: Australian Academic Press, 2004.

Stallard, Paul, Gordon Taylor, Rob Anderson, Harry Daniels, Neil Simpson, Rhiannon Phillips, and Elena Skryabina. "School-based intervention to reduce anxiety in children: study protocol for a randomized controlled trial (PACES)." Trials 13, no. 1 (2012): 227.

Available at: https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-227

Evaluation details

Methods

The evaluation investigated the effect of a classroom-based cognitive behaviour therapy prevention programme (FRIENDS) on anxiety symptoms in children. The study deployed a three-group parallel cluster randomised controlled trial between September, 2011, and July, 2012, with school as the unit of allocation and individual participants as the unit of analysis. Once all schools had been enrolled, year groups were randomly assigned (1:1:1) to school-led FRIENDS (sessions delivered by school staff), health-led FRIENDS (sessions delivered by health professionals), or usual school provision (PSHE). Randomisation was undertaken at school and not the class level to avoid possible contamination within schools. Trial groups were balanced with respect to key characteristics by calculating an imbalance statistic for a large random sample of possible allocation sequences. Researchers who analysed data were masked to allocation.

Child outcomes were collected during class time with self-completed questionnaires administered by researchers (masked to allocation) at baseline, 6 months, and 12 months. The primary outcome was symptoms of anxiety and low mood 12 months after baseline as established by the Revised Child Anxiety and Depression scale (RCADS 30). Parents and school teachers also completed screening and impact questionnaires.

In the statistical analysis, the study was powered to detect a difference of 3·6 points in mean RCADS total scores between FRIENDS and usual PSHE. On the basis of an SD of 12 points and an intra-cluster correlation coefficient of 0·02, 28 pupils per class, 90% consent and 80% retention, effect sizes between 0·28 and 0·30, SDs are detectable with 80% power and 5% two-sided α with 1134–1360 assenting pupils.

Descriptive statistics were used to assess the balance between the trial groups at baseline.  To take appropriate account of the hierarchical nature of the data, multivariable mixed effects models were used to compare mean RCADS at 12 months for health-led FRIENDS with school-led FRIENDS and usual school provision, with adjustment for baseline RCADS, sex, and school effects. For RCADS, repeated-measures mixed-effects analysis of variance models were used to investigate convergence and divergence between trial groups over time. Pre-planned subgroup analyses were conducted with interaction terms in the regression models between the randomised group and the baseline variable. Sensitivity analyses were conducted to assess the potential effect of missing data.

Findings

40 schools took part in the trial: 14 (n=497 children) were randomly assigned to school-led FRIENDS, 14 (n=509) to health-led FRIENDS, and 12 (n=442) to usual school provision. 1257 (92%) children completed 12 month assessments (449 in health-led FRIENDS, 436 in school-led FRIENDS, and 372 in usual school provision). The study recorded a difference at 12 months in adjusted mean child-reported RCADS scores for health-led versus school-led FRIENDS (19·49 [SD 14·81] vs 22·86 [15·24]; adjusted difference –3·91, 95% CI –6·48 to –1·35; p=0·0004) and health-led FRIENDS versus usual school provision (19·49 [14·81] vs 22·48 [15·74]; –2·66, –5·22 to –0·09; p=0·043). Analysis of other secondary outcomes and parent and teacher completed measures identified no differences between treatment groups at 12 months.

Separate subgroup analysis in children with the highest 10% of baseline RCADS scores (high anxiety ≥49) and the remaining 90% (low anxiety ≤48) were also conducted. The results show a significant within-group reduction for the high-risk group at 12 months but no effects between groups. For the low-risk group, we noted between-group differences in mean RCADS at 12 months. Adjusted mean differences showed an effect for health-led FRIENDS versus school-led FRIENDS (adjusted difference –3·78, 95% CI –6·16 to –1·40; p=0·003) and health-led FRIENDS versus usual school provision (–3·13, –5·61 to –0·65; p=0·015). This effect relates to a reduction in the health-led FRIENDS group on the social and generalised anxiety subscales

The main interpretation provided by the study points out that universally delivered anxiety prevention programmes can be effective when used in schools. However, programme effectiveness varies depending on who delivers them.

Bibliography

Stallard, Paul, Elena Skryabina, Gordon Taylor, Rhiannon Phillips, Harry Daniels, Rob Anderson, and Neil Simpson. "Classroom-based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES)." The Lancet Psychiatry 1, no. 3 (2014): 185-192. Available at: http://www.sciencedirect.com/science/article/pii/S2215036614702445

Contact information

Email

epic@rand.org

Last updated

November 2017

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