Menu
  • CPD online - National Elf Service
  • Take your event #BeyondTheRoom
  • Training
  • #ElfHelp
  • Contact us
  • News

No bias. No misinformation. No spin. Just what you need!

The Mental Elf

  • Home
  • About
  • Categories
      • Cost effectiveness
      • Evaluation and impact assessment
      • Financial management
      • Financial sustainability
      • Integration
      • Needs assessment
      • Outcomes based commissioning
      • Partnership working
      • Population health
      • Resource allocation
      • Service reconfiguration
      • Service review and improvement
      • Specialised commissioning
      • Strategy development and planning
      • Technology
      • Urgent care
      • Variation
      • caries
      • cleft lip and palate
      • dental workforce
      • endodontics
      • oral and maxillofacial surgery
      • oral cancer
      • oral health
      • oral medicine and pathology
      • orthodontics
      • periodontal disease
      • restorative dentistry
      • temporomandibular joint disorders
      • tooth surface loss
    • Diagnosis
      • brain imaging
      • diagnostic test
      • risk factors
      • screening programme
      • screening test
      • behaviour
      • ICT
      • learning styles
      • numeracy
      • phonics
      • reading
      • science
      • social emotional
      • social skills
      • wellbeing
      • autistic spectrum disorder
      • challenging behaviour
      • communication
      • down syndrome
      • parents with learning disabilities
      • prader-willi syndrome
      • profound and multiple learning disability
    • Mental health
      • ADHD
      • anxiety
      • bipolar disorder
      • dementia
      • depression
      • eating disorders
      • OCD
      • panic disorder
      • personality disorders
      • psychosis
      • PTSD
      • schizophrenia
      • self-harm
      • sleep disorders
      • substance misuse
      • suicide
      • autoimmune and inflammatory diseases
      • fibromyalgia
      • fractures and dislocations
      • musculoskeletal pain
      • neck and back pain
      • osteoarthritis
      • osteoporosis
      • rheumatoid arthritis
      • soft tissue injuries
      • spinal conditions
      • spondyloarthropathies
    • Other health conditions
      • blood-borne viruses
      • cancer
      • cardiovascular disease
      • chronic fatigue syndrome
      • comorbidity
      • epilepsy
      • multiple sclerosis
      • sleep apnoea
      • traumatic brain injury
    • Populations and settings
      • advocacy
      • black and minority ethnic
      • caregivers
      • child and adolescent
      • commissioning
      • community settings
      • crime
      • deinstitutionalisation
      • employment
      • end of life
      • family carers
      • hospital admissions
      • housing
      • later life
      • LGBTQ+
      • liaison psychiatry
      • loneliness
      • older adult
      • parenting
      • patient safety
      • perinatal mental health
      • poverty
      • pregnancy
      • primary care
      • quality of life
      • schools
      • secondary care
      • service user involvement
      • shared care
      • sport
      • training
      • vulnerable people
      • young adult
    • Publication types
      • appraisal
      • audit
      • case study
      • case-control
      • cohort study
      • consultation
      • cross-sectional
      • economic analysis
      • economic evaluation
      • guideline
      • legislation
      • literature review
      • meta-analysis
      • mixed methods
      • observational study
      • patient information
      • policy
      • prospective study
      • qualitative
      • questionnaire
      • randomised controlled trial
      • report
      • scoping review
      • statistics
      • survey
      • systematic review
      • technology assessment
      • training resource
      • umbrella review
      • website
      • coproduction
      • equality and diversity
      • evidence based social care
      • home care
      • integration
      • local authorities
      • nursing homes
      • personal budgets and direct payments
      • personalisation
      • reablement
      • residential care
      • safeguarding
      • social care decision making
      • social care training
      • social care workforce
      • social work
      • support planning
      • user led organisations
      • voluntary and community sector
    • Treatment
      • antidepressants
      • antipsychotics
      • CBT
      • cognitive bias modification (cbm)
      • complementary and alternative
      • digital health
      • exercise
      • medicines
      • mental illness prevention
      • mindfulness
      • other
      • psychotherapy
      • rehabilitation
      • self-management
      • surgical
      • systems
      • telehealth
      • topical
  • Podcasts
Search

Home » Posts » Treatment » CBT » School-based CBT for anxiety and low mood: the FRIENDS programme

School-based CBT for anxiety and low mood: the FRIENDS programme

73 Responses »
Mar 8 2016
Profile photo of Alan Underwood
Posted by
Alan Underwood
4549150256_32bfd4f0d5_b

Anxiety and depressive disorders in children are common. The British Mental Health survey estimated that 3.7% of 5-15 year-olds met the diagnostic criteria for an anxiety disorder and 1% had a depressive disorder. Co-morbidity between anxiety and depression is common and around 15-18% of children will have experienced an impairing anxiety or depression by the age of 16-17 years old.

The prevalence of emotional problems, which often can persist into adulthood and the subsequent impact on individuals’ lives, is a major public health issue. The difficulty is that many children who experience anxiety and depression will not access evidence based treatment or specialist services. Very few will receive any form of help.

A recently published NIHR-funded study attempts to address this problem by focusing on the delivery of a prevention programme delivered in schools.

Around 1 in 6 young people will have experienced an impairing anxiety or depression before age 18.

Around 1 in 6 young people will have experienced an impairing anxiety or depression before age 18.

Methods

The study employed a pragmatic, cluster three arm RCT (randomised controlled trial) design.

The three arms were:

  1. FRIENDS delivered by health staff
  2. FRIENDS delivered by school staff
  3. The usual school curriculum (PSHE).

Break down of study arm and delivery

  • 40 schools in the south of England (within a 50 mile radius of Bath) were recruited and 1,448 children were eligible for the study, of which 1,392 consented to take part.
  • The only exclusion criteria was for children 9-10 years old who were not attending school or did not participate in PSHE for religious or other reasons.
  • The FRIENDS intervention consisted of a manualised CBT programme delivered over 9 one-hour sessions. The programme focused on increasing emotional awareness, emotional regulation, problem solving and coping skills to reduce avoidance.
  • PHSE sessions were provided by the school and followed the UK national curriculum programme.
  • Outcome data was collected at 6, 12 and 24 months. The primary outcome was the Revised Child Anxiety and Depression Scale (RCADS)
  • Questionnaires were administered by researchers who were blind to the children’s treatment allocation.
  • The data analysis was assessed using an intent-to-treat analysis without the use of imputation. Pre-defined analysis was conducted with corrections for multiple analysis applied.
  • The authors also conducted an economic analysis, which compared each of the interventions and focused on the service usage (e.g. visits to a GP, outpatient appointment and A&E visits).

Results

  • All 9 FRIENDS sessions were delivered in both treatment arms in the allocated schools. Fidelity raters who were independent of the study rated them as good. However, this was based on a sample of just one single session.
  • In the Health-led FRIENDS sessions, 100% of the core tasks and homework were delivered. In the School-led FRIENDS, only 60% of the core task and homework were delivered.
  • Outcomes at 12 months showed a difference in adjusted mean RCADS scores between Health-led and School-led FRIENDS (Adjusted Difference -3.91, 95% Confidence Interval -6.48 to -1.35; p=0.0004)
  • There was also a difference between Health-led and School-led FRIENDS and usual school provision (Adjusted Difference -2.66, 95% Confidence Interval -5.22 to -0.09; p=0.043) at 12 months.
  • There were 12-month differences in the RCADs scores for generalised and social anxiety, but not for depression.
  • A pre-defined sub group analysis of high- and low-risk groups was also conducted at 12 months. Authors reported significant reductions in the high-risk group, but no difference between the Health-led and School-led FRIENDS interventions. There was a small treatment effect for both Health-led FRIENDS (Cohens d=0.22, 95% CI 0.38 to 0.07) and School-led FRIENDS (Cohens d= 0.25, 95% CI 0.40 to 0.11) in the low risk group.
  • Outcomes at 24 months were based on 43.6% of the original sample. The differences observed between interventions had diminished across all three groups and there were no between group differences in total anxiety. There was no difference between high- and low-risk groups at 24 months.
Children’s anxiety levels improved irrespective of the intervention that they received.

Children’s anxiety levels improved irrespective of the intervention that they received.

Conclusions

  • The authors concluded that the FRIENDS programme was acceptable to both children and school staff. It was also possible to integrate the FRIENDS programme successfully into the academic teaching timetable.
  • In the short-term, the effectiveness of the programme depended on who was delivering it with Heatlh-Led FRIENDS achieving greater reductions in anxiety at 12 months.
  • However at 24 months the between-group effects had reduced and there was no between-group effects present.
  • The authors reported no evidence of cost effectiveness for the universal delivery of the FRIENDS program over a 6-month period.
  • Economic analysis did not detect change in service usage of a 6-month period post-intervention, however this was based on a small subset of the overall sample and it could be argued that service usage is a low frequency event, which may mean a longer time period was needed to capture potential benefits.
This RCT does not support the universal provision of specific anxiety prevention programmes in UK primary schools.

This RCT does not support the universal provision of specific anxiety prevention programmes in UK primary schools.

Strengths and limitations

  • This study has several strengths; firstly the authors provided a clear and transparent report of the methodology, analysis strategy and findings and in addition pre-registered both the 12 and 24 months parts of the study. The authors also provided a power calculation to allow the reader to determine if the study was appropriately powered. This is a really great example of the authors showing their working. Others publishing intervention trials should follow this example.
  • In terms of addressing potential sources of bias, the authors address this in multiple ways. Independent assessors were used in the randomisation, data collection and rating of fidelity. It would have been good to know if the authors had been blind to the allocation until the analysis was complete, as this would have added another layer of rigour to reducing possible sources of bias.
  • Regarding limitations in the sample, this only included schools in a 50-mile radius of a city in southern England (Bath). It is not clear if the findings would be generalisable to other areas of the UK or a more urban environment (e.g. London). Also there was no assessment or control for the relative levels of social economic deprivation as these have often been cited as leading to poorer outcomes across health (Wilkinson & Picket, 2009). Including such an analysis may have identified who the intervention was most or least effective for.
  • There was also substantial attrition at 24 months and as a consequence effects may have been masked by the reduction in the data pool and the relative reduction in power to detect if an effect was present. Also the economic analysis was based on a small subtest of the sample over a short period of time and as such the conclusions of effectiveness are limited, although the authors freely point this out in the paper.

Discussion

This large and well-conducted trial throws up a number of questions. The recent government announcement to increase funding in mental health (HM Government, 2016) emphasised the need to invest in provision to young people. The key question is, how can this be well targeted in a cost-effective manner. The concept of universal provision, with the aim of preventing anxiety in children, appears at least from this study to have limited support, as the interventions performed no better than each other at 24 months. This may speak to the existing strengths of PHSE education and also little need for health professional involvement in delivery. Currently it would seem this approach would be outside of the financial abilities of most schools. Also it is unclear how well any intervention would generalise to more diverse schools and in highly economically deprived areas.

Most interesting is that it appears that the delivery of the programme had the same effect even when only 60% of the core material and between session tasks were assigned. It may therefore be useful for future research to establish the active ingredients of the interventions, which may lead to a reduced cost. The alternative is to research to identify those who are at risk of developing anxiety and depression at a young age and target interventions at this group, rather than pursing a course of universal delivery.

The rates of anxiety and depression in children is still a major public health concern, but this study suggests blanket delivery of prevention programmes in schools may not be the answer to nudging children away from a trajectory of developing anxiety or depressive disorder.

This study suggests that universal provision may not be a sensible option, but even if it was, can we afford it?

This study suggests that universal provision may not be a sensible option, but even if it was, can we afford it?

Links

Primary paper

Stallard P, Skryabina E, Taylor G, Anderson R, Ukoumunne OC, Daniels H, et al. A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years. Public Health Res 2015;3(14)

Other references

HM Government (2016) Prime Minister pledges a revolution in mental health treatment. 11 Jan 2016.

Wilkinson R, Pickett K. (2009) The Spirit Level: Why equality is better for everyone. Penguin Books.

Photo credits

  • Denis Mihailov CC BY 2.0
  • Todd Huffman CC BY 2.0
  • Alexis Nyal CC BY 2.0
  • Rae Allen CC BY 2.0
  • Tax Credits CC BY 2.0
Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+
Mark as read

Share this post:

Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+ Share via email
Create a personal elf note about this blog
Tagged with: anxiety, anxiety disorders, child and adolescent, cognitive behavioural therapy, cost effectiveness, depression, mental illness prevention, Personal social health and economic (PSHE) education, randomised controlled trial, school-based interventions, schools, youth mental health
Profile photo of Alan Underwood

Alan Underwood

Alan is a Specialist Clinical Psychologist working in medium secure forensic services and a course tutor at UCL on the PG Cert in Low Intensity Psychological Interventions. Prior to completing clinical training at UCL he  worked at Sutton and Merton IAPT as a PWP and Team Coordination (Senior PWP) and delivered CBT informed low intensity interventions.   He has interests in forensic mental health,psychological therapy, anxiety disorders (particularly GAD), intervention design and evaluation.

More posts

Follow me here –

  • Twitter
Logging In...

Profile cancel

Sign in with Twitter Sign in with Facebook
or

Not published

  • 73 Replies
  • 3 Comments
  • 60 Tweets
  • 0 Facebook
  • 2 Pingbacks
Last reply was January 29, 2019
  1. @iVivekMisra
    View March 8, 2016

    School-based CBT for anxiety and low mood: the FRIENDS programme https://t.co/ifHdtozBTh #MentalHealth https://t.co/Esr16YPG2X

    Reply
  2. @Mental_Elf
    View March 8, 2016

    School-based CBT for anxiety and low mood: the FRIENDS programme RCT https://t.co/dZd9uYN3ut

    TheChildElf retweeted thiswighttime retweeted thisEducationElf retweeted thisTheProjectYP retweeted thismartingray01 retweeted thiscemarshall2 retweeted thisjustinerooke retweeted thiswistfulwordsof1 retweeted thisFewingsBj retweeted thisUoMCounsPsych retweeted thisEaTUoM retweeted thisDLapthorne retweeted thisCNWLlibraries retweeted thisneallj retweeted thisfearandworry retweeted thisdavidbriess retweeted thisAl_Turner_ retweeted thisLisaLouD1 retweeted thiskate17929 retweeted thisAnDY_Res_Clin retweeted thisAILAHT0909 retweeted this... and 11 more
    Reply
  3. @Mental_Elf
    View March 8, 2016

    Today @weeal36 on school-based CBT for anxiety & low mood in 9-10 year olds https://t.co/dZd9uYN3ut #FRIENDS @NIHR_DC

    KarenSykes2 retweeted thisweeal36 retweeted thisYmhMatters retweeted this
    Reply
  4. @lindakDprof
    View March 8, 2016

    School-based CBT for anxiety and low mood: the FRIENDS programme https://t.co/DR9v8YOEKg via @sharethis. We need school CBT therapists.

    Reply
  5. @Mental_Elf
    View March 8, 2016

    RCT finds little evidence to justify the widespread use of universal anxiety prevention programmes in schools https://t.co/dZd9uYN3ut

    RecoveryMum retweeted thisspawneedave retweeted thishelensharpe1 retweeted thisIOWNHSLibrary retweeted thisTarikEndale retweeted this
    Reply
  6. @Mental_Elf
    View March 8, 2016

    1 in 6 young people will have experienced an impairing anxiety or depression before age 18 https://t.co/jO0qovIXIM https://t.co/voTTVUUipM

    ConorAllanIRL retweeted thisPsychCB retweeted thisrebabur retweeted thisLorenzKH retweeted thisJPW066 retweeted thisGleamsofsun retweeted thisCleeeeena retweeted thisHAS_veille retweeted thisTeamworkTrust retweeted thismindinbexley retweeted thisApplebyAppleby retweeted thisBeGOOD_EIE retweeted thisMGriffinDoyle retweeted thisSmay54May retweeted thisTanyaBalcke retweeted thisFlowzoneE retweeted thisJenny_Edwards retweeted thisdobbing_ceri retweeted thisRachelHadland retweeted this... and 9 more
    Reply
  7. @WorswickIzzy
    View March 8, 2016

    RT @Mental_Elf: Don’t miss – School-based CBT for anxiety and low mood: the FRIENDS programme https://t.co/dZd9uYN3ut #EBP

    matkinson956 retweeted thisFirefly_fan retweeted thisCharlotdot retweeted thispsychiatryofid retweeted thisC_2me retweeted thisSWManMet retweeted this
    Reply
  8. @jennifer_brophy
    View March 8, 2016

    Nice analysis of a school based programme. Question to be raised re accessibility for children with any SLC needs. https://t.co/jG0e2dL0Ir

    DunphyEdel retweeted thisweeal36 retweeted this
    Reply
  9. @felly500
    View March 8, 2016

    School-based CBT for anxiety and low mood: the FRIENDS programme
    @DrSNThomas https://t.co/Jqgnh9R00k

    jgcope retweeted thisAngelaPedderNHS retweeted this
    Reply
  10. @KathEvans2
    View March 9, 2016

    RT @Mental_Elf: School-based CBT no better than standard PSHE for reducing anxiety in primary school children, says new RCT https://t.co/dZ…

    Reply
  11. BibSonomy :: url :: Preventing anxiety and low mood with school-based CBT- Mental Elf Blog post.
    View March 10, 2016

    […]  1Preventing anxiety and low mood with school-based CBT- Mental Elf Blog post.   […]

    Reply
  12. Adrian
    View March 12, 2016

    FRIENDS is not actually CBT? https://www.friendsprograms.com/friends-for-life/

    Reply
    • Alan Underwoodreplied:
      View March 13, 2016

      Dear Adrian, The programme evaluate by the authors’ of the paper is described on pg 6 of the full report:

      “The FRIENDS programme is a manualised CBT programme designed to improve children’s emotional
      health.41 Each child has his or her own workbook and group leaders have a comprehensive manual
      specifying key learning points, objectives and activities for each session. The intervention trialled in this
      study involved nine 60-minute weekly sessions delivered to whole classes of children (i.e. universal
      delivery). Written work is kept to a minimum and each session uses a variety of different materials and
      activities to engage and maintain interest. The feasibility and viability of delivering the FRIENDS programme
      in UK schools has previously been established.35–37
      The FRIENDS programme is based on the principles of CBT and develops skills to counter the cognitive,
      emotional and behavioural aspects of anxiety. Children develop emotional awareness and regulation skills
      to enable them to identify and replace anxiety-increasing cognitions with more balanced and functional
      ways of thinking and to develop problem-solving skills to confront and cope with anxiety-provoking
      situations and events. The programme therefore teaches children skills to identify and manage their
      anxious feelings, develop more helpful (anxiety-reducing) ways of thinking and face and overcome fears
      and challenges rather than avoid them.”

      I hope that clarifies the interventions theoretical Underpinnings. Best A.

      Reply
      • Adrianreplied:
        View March 14, 2016

        yep but if you look on the FRIENDS site https://www.friendsprograms.com/friends-for-life/ the key messages appear to be;

        Feelings (talk about your feelings and care about other people’s feelings)
        Relax (do “milkshake” breathing, have some quiet time)
        I can try ! (we can all try our best)
        Encourage (step plans to happy home)
        Nurture (quality time together doing fun activities)
        Don’t forget – be brave! (practice skills everyday with friends /family)
        Stay happy

        Reply
  13. Can gamified cCBT prevent depression in secondary school students?
    View January 29, 2019

    […] Mental Elf has covered this extensively, with recent blogs on depression prevention programmes, school-based CBT for anxiety and low mood, mindfulness in schools, trajectories of depression in young people, targeting unhelpful […]

    Reply
Try out our members features!

Sign up now. It’s free! Or Sign in

We can help you:

  • 1Keep up to date with the latest research
  • 2Connect with experts and colleagues
  • 3Contribute to your professional development
Tell me more about the benefits of membership

FOLLOW the Mental Elf

  • Find us on Facebook
  • Follow us on Twitter
  • Follow us on Google+
  • Read our RSS feed
  • Find us on LinkedIn

Twitter

  • @n_higsonsweeney We elves are so pleased that you've agreed to join the woodland team Nina 🌳🌤🍄 Can't wait to get st… https://t.co/LgXFj9R17D about 1 hour ago Reply Retweet Favorite
  • RT @n_higsonsweeney: Very excited to share that I am joining the team over at the @Mental_Elf as an Elf Coordinator! 🥳 My main role will be… about 1 hour ago Reply Retweet Favorite
  • A *very* exciting new funding opportunity from the @wellcometrust "Understanding and unpacking debates in mental… https://t.co/JoEs3UELig about 7 hours ago Reply Retweet Favorite
  • RT @DafniK10: Great blog by @donamatthews today on the elevated suicide risk after a diagnosis of severe physical health condition. Posing… about 9 hours ago Reply Retweet Favorite
  • "Compassionate public policy needs to promote collaborative care teams to support patients’ optimal overall health.… https://t.co/RjmnquqZ5p about 20 hours ago Reply Retweet Favorite
Mental_Elf

Recent Posts

  • Does a diagnosis of severe physical illness elevate suicide risk?
  • Trauma transmission in the children of trauma-affected refugees: risk and protective factors
  • Ketamine and suicidal ideation: French trial finds modest short-term effects
  • Mental disorder and homicide: are rates and sentencing patterns changing?
  • Can social recovery therapy improve social disability in young people?

Recent Comments

  • julian on Mental disorder and homicide: are rates and sentencing patterns changing?
  • Lorna on Is it bipolar disorder or borderline personality disorder?
  • Jean Sellar-Edmunds on Antidepressant withdrawal or depression relapse? International guidelines on antidepressant discontinuation are unclear

Suggest a paper

Do you have a suggestion for a paper? Then let us know.

Click here

Watch our 2 minute promo video!

Visit our other Elf blogs

  • Commissioning
  • Dentistry
  • Education
  • Learning Disabilities
  • Mental Health
  • Musculoskeletal
  • Social Care

Free trial

Close
Ready to get started? It's free!
Sign up now No thanks Tell me more about the benefits of membership

Free email newsletter

FOLLOW the Mental Elf

  • Find us on Facebook
  • Follow us on Twitter
  • Follow us on Google+
  • Read our RSS feed
  • Find us on LinkedIn
© 2023 National Elf Service is brought to you by Minervation Ltd
Email: info@nationalelfservice.net
  • About
  • Evaluation
  • Site Map
  • Terms
  • Privacy
  • Cookies
  • Log In