CBT PROGRAMS

FOR ANXIETY
COOL KIDS VS.
FRIENDS

EDPS 612.03
Melissa Martin
Katie Humilde
David Ki
Alicia Marchini

ANXIETY
Why anxiety prevention programs are important
Anxiety disorders are one of the most prevalent childhood mental disorders
(Ford, Goodman & Meltzer, 2003).
Anxiety disorders are related to higher rates of depression, attention and
concentration difficulties, poor self-esteem, and increased difficulty developing peer
relationships and social behaviours (Costello, mustillo, Erkanli, Keeler, & Angold,
2003).

ANXIETY IN CHILDREN AND YOUTH

U.S. study in 2012

Survey of 10,123 adolescents aged 13-18 years

Stats Canada report in 2013

2.4 million reported symptoms with GAD
Life time prevalence rate = 8.7%
12 month prevalence rate =2.6% (in 2012)
(Burstein et al., 2012; Pearson, Janz, & Ali, 2013)

ANXIETY IN CHILDREN AND YOUTH

Canada 2006 Census
14.7% of 2-5 years reported having emotional anxiety problems

Canadian Community Health Survey 2009

(Public Helath Agency of Canada, 2011; Statistics Canada, 2009)

INTRODUCTION: CBT FOR ANXIETY

According to Mennuti and Christner (2012), cognitivebehavioural therapy (CBT) emphasizes:
perception of experiences
how perceptions influence behaviour and emotions

COOL KIDS: AN OVERVIEW

Developed by Lyneham, Abbott, Wignall and Rapee in 2003 through
the Centre for Emotional Health in Sydney Australia which is run
through McQuarie University in 2008. (Chalfant et al., 2006)
Designed to treat anxiety with small groups of at risk for or already
diagnosed children with anxiety disorders.
There are program variations designed for kids from ages 7-16.
Cool Kids also offers a Preschool Intervention that targets parents as
agents of change for their children.
Cool Kids provides intervention based on teaching cognitive
strategies, structured homework, and exposure to anxiety triggers.
(Lyneham, Abbott, Wignall & Rapee, 2003)

COOL KIDS: IN ACTION

A trained counselor/psychologist implements the program in small groups of
approximately 6 children. (McLoone, Hudson, & Rapee, 2006).
There are 10 one hour lessons that are completed once a week. In a school
system this is typically done in a pull out format.
The course of treatment involves two booster sessions that can be delivered
after school hours.
Parent coaching is an integral part of the program. The counselor meets
independently with each parent once at the start of the program and again
midway through the program.
(McLoone, Hudson, & Rapee, 2006)

COOL KIDS STRENGTH #1

Strength #1: It is a structured, skills-based program that
teaches both children and their parents to manage the
childs anxiety.
child and the parents participate
learn practical skills
better school attendance, higher academic achievement, greater selfconfidence, more friendships
less worrying, shyness, fear, and stress in the family

COOL KIDS STRENGTH #2

Strength #2: The program targets a wide age range.
The original program targets children, ages 7 to 17
slightly different versions for younger children (up to age 12) and older
children (ages 13 to 17)

COOL KIDS STRENGTH #3

Strength #3: There are different versions of Cool Kids to
target various specific groups using specialized delivery.
version for delivery in schools and a version for teenagers with both anxiety and
depression
delivered face-to-face, over internet, on a CD recording, or over telephone
PROOF: Study of 43 teens (ages 14-17) with a diagnosis of anxiety showed
improvements from 12-week, computerized Cool Teens program on a CD-ROM
(supplemented with phone calls from a therapist and support from parents)
Post-treatment & at 3-month follow up: Teens in the Cool Teens program had
significant reductions in the number of anxiety disorders, severity of anxiety,
internalizing symptoms, automatic thoughts, and life interference
User-friendly: users indicated that there were few barriers and that it was well suited
to adolescents with anxiety

COOL KIDS STRENGTH #3

Strength #3: There are different versions of Cool Kids to
target various specific groups using specialized delivery.
adapted and implemented to help alleviate anxiety in students with
high functioning ASD
PROOF: Chalfant, Rapee, and Carrol (2006): 47 school-age children
with high functioning autism
Children who received 12-week, group-delivered adapted Cool Kids
program showed significant reductions in anxiety symptoms and were
better able to identify their automatic thoughts, and had a significant
reduction in automatic thoughts, compared to those in the wait-list condition
71.4% no longer met the criteria for an anxiety disorder

COOL KIDS STRENGTH #4

Strength #4: The Cool Kids program has also been
translated into many languages and is used in countries
around the world
shows a high degree of adaptability to different cultures and settings
PROOF: In regard to remote areas with populations that emphasize traditions
(e.g., Aboriginal peoples), Cool Kids can be effectively adapted
Michael Davies (2011): Cool Kids was chosen as the program to evaluate in terms of
the practicality of adapting it to address anxiety in Aboriginal children in a remote
location
concluded that Cool Kids is flexible enough to be adapted to remote settings, while
staying true to core structure and targets
can adhere to cultural protocol and respect traditions, while remaining effective

COOL KIDS STRENGTH #5

Strength #5: It is effective!!!
PROOF: Study of 260 children (ages 6-12) with anxiety disorders
significantly greater number of those in the Cool Kids program no
longer met criteria for anxiety disorder after treatment, compared to
waitlist condition or bibliotherapy
still less likely to meet criteria after three months
children in Cool Kids program had the greatest significant reductions
in the severity of disorder, anxiety symptoms, and in internalizing
and externalizing behaviour, even after 3 months

COOL KIDS STRENGTH #5

Strength #5: It is effective!!!
PROOF: Mifsud & Rapee, 2005: Study of children with anxiety in a low
socio-economic area
children in 10-week Cool Kids program showed significant
reductions in anxiety symptoms and fewer related problems,
compared to those who did not receive treatment
indicates that students from various economic statuses have similar
positive outcomes from the Cool Kids program

COOL KIDS STRENGTH #6

Strength #6: Its benefits are greater than the cost.
costs about $660 (includes all treatment manuals, materials, and
sessions)
varies depending on the version and form of delivery
roughly $55/session = reasonable, especially considering results and
skills that are developed

COOL KIDS: QUESTIONS

Points to
consider.

COOL KIDS: Questions to Ponder

Question #1: Is the Cool Kids Program time and cost
effective?
The program is designed for small groups (approximately 6 children).
require more program leaders (e.g., trained teachers, mental health professionals) than
intervention programs designed for big groups.
The Cool Kids program is a Tier 2/ Tier 3 intervention which targets at-risk children/youth.
requires screening and assessment which are often time-consuming and expensive. (LowryWebster, Barrett, & Dadds, 2001)

Lau & Rapee (2011) highlighted the importance of prevention for cost-effectiveness in an
intervention program.
identification of appropriate children for indicated interventions is also a complex issue, and
no ideal method exists. All forms of assessment will be associated with their own errors and
biases. (Lau & Rapee, 2011, p. 263).

COOL KIDS: Questions to Ponder

Question #2: Is the Cool Kids Program appropriate for school
settings?
small groups (approximately 6 children), requiring a greater number of program leaders,
need for screening and assessment. Group facilitators need to be trained counsellors or
psychologists, which may not be suitable for a school setting.
Comparatively few children with significant emotional disorders receive interventions from
specialist child mental health services.
53.1% of children with significant emotional disorder had no contact with any front line
or specialist mental health services over an 18-month period (Ford, Goodman, & Meltzer, 2003).

COOL KIDS: Questions to Ponder

Question #3: Are there any concerns with implementing a
small group program specifically to children who are at risk for
anxiety?
McLoone, Hudson, & Rapee (2006) discussed how FRIENDS allows all children to participate, reducing
the likelihood of stigmatization in an integrated setting.
Cool Kids is provided to small groups of targeted youth. If it is offered in a school-setting where they may
need to be pulled out of the classroom, there may be a risk of stigmatization.
McLoone et al. (2006) also mention how there may be parental concerns with them not being on board
with anxiety intervention programs, especially if they were previously unaware that their child may be at
risk for anxiety. They may also be concerned of their child being stigmatized or labelled.
Parents also fear that children placed in an anxiety group may become more distressed, forming new
concerns based on the anxieties reported by other group members (McLoone et al, 2006).

COOL KIDS: Questions to Ponder

Question #3 (Contd)
The California Evidence-Based Clearinghouse for Child Welfare in regards to training and program
implementation
Cool Kids does not directly provide services to parents
Cool Kids does have a training manual and offers educational training programs
There are no pre-implementation materials to measure organizational or provider readiness for the Cool
Kids Program
There is no formal support available for the implementation of Cool Kids
There is a fidelity measure that is available upon request (a checklist of skills and strategies)
There is an implementation guide in the form of a program manual:
http://www.centreforemotionalhealth.com.au/pages/resources-products.asp
California Evidence-based Clearinghouse for Child Welfare
(2015)

COOL KIDS: Questions to Ponder

Question #4: Is there enough research to prove that Cool Kids
is an effective, evidence-based program for children with
anxiety?
The California Evidence-Based Clearinghouse for Child Welfare (CEBC4CW) rated the Cool Kids
Program a 3 out of 5 as having promising research evidence

The program must have at least one study establishing its benefit over a control group or found to be
better than an appropriate comparison practice.

California Evidence-based Clearinghouse for Child Welfare

(2015)

COOL KIDS: Questions to Ponder

Question #4 (Contd)
The California Evidence-Based Clearinghouse for Child Welfare (CEBC4CW) posted the following five
articles as peer reviewed studies on their website:
Rapee, R.M. (2000). Group treatment of children with anxiety disorders: outcome and predictions of
treatment response. Australian Journal of Psychology, 52(3), 125-129.
Rapee, R.M., Abott, M.J., & Lyneham, H.J. (2006). Bibliotherapy for children with anxiety disorders
using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical
Psychology, 74(3), 436-444.
Chalfant, A. & Rapee, R.M. (2007). Treating anxiety disorders in children with high functioning autism
spectrum disorders: A controlled trial. Journal of Autism and Developmental Disorders, 37, 1842-1857.
Hudson, J.L., Rapee, R.M., Deveney, C., Schniering, C.A., Lyneham, H.J., & Bovopoulous, N. (2009).
Cognitive behavioral treatment versus an active control for children and adolescents with anxiety
disorders: A randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry,
48(5), 533-544.
California Evidence-based Clearinghouse for Child Welfare (2015)

COOL KIDS: ANSWERS

New thoughts to
ponder.

COOL KIDS: Response to Question # 1

Question #1: Is the Cool Kids Program time and cost effective?
this is limitation can also be considered to contribute to the strength of
the program
small group intervention allows for more attention on each child
a trained professional must implement it, which ensures correct and
effective implementation of the program to produce positive results
Screening and assessment can be expensive, but the results of the
program are long lasting = benefits outweigh costs
reduced costs are often offered for the clinical assessment (at $155)
when Clinical Masters students conduct them

COOL KIDS: Response to Question # 2

Question #2: Is the Cool Kids Program appropriate for school
settings?
several effective versions of the intervention
some are at-home versions, which is an important setting for youth
parents are included in the intervention program (contributes to success)
children dont always want to participate in such programs at school
because of stigma (i.e., being pulled out of class or cant attend recess
because of the program makes them different)
beneficial for the child to have an at-home or clinic option

COOL KIDS: Response to Question # 3

Question #3: Are there any concerns with implementing a small
group program specifically to children who are at risk for
anxiety?
parents are not supposed to guide the treatment they are only
supposed to be there for encouragement
children are learning the skills to cope on their own
trained professional and training manual are offered by the program,
making pre-implementation material unnecessary
counsellors are typically available for in person or over the phone
contact throughout the program to provide support

COOL KIDS: QUESTIONS TO PONDER

Question #4: Is there enough research to prove that Cool Kids
is an effective, evidence-based program for children with
anxiety?
Article not authored or co-authored by original developers:
Anxiety in children: remote area sensitivities and considered
changes in structuring a Cool Kids approach by Michael Davies
The previously noted studies are peer-reviewed, so the quality of
research is up to editorial standards

FRIENDS: OVERVIEW
Universal

preventative program for anxiety and depression

Skills covered in the programs are represented in the letters of the

acronym
F: Feelings
R: Remember to relax. Have quiet time
I: Inner helpful thoughts
E: Explore solutions and coping step plans
N:Now reward yourself.
D: Dont forget to practice
S: Stay calm you know how to cope now

FRIENDS: OVERVIEW
Program

goals:

Normalize the emotional state of anxiety

Teach skills for effectively coping with stress, challenges, and change
Increase emotional resilience and problem-solving abilities
Build friendships and support networks
Enhance self-confidence and self-esteem
Empower children, families, and professionals by each sessions
Prevent the development of anxiety and depressive symptoms

(FRIENDS can help, n.d.)

FRIENDS: OVERVIEW
The

program consists of 3 developmentally sensitive versions:

Fun Friends (K-Grade 1, 4-7 years)

FRIENDS for Life (Grade 2-6, 8-11 years)
My FRIENDS Youth (Grade 7-10, 12-16 years)

(FRIENDS can help, n.d.)

FRIENDS: FRAMEWORKS
Theoretical Frameworks (Pahl & Barrett, 2007)

FRIENDS: CBT
Theoretical Frameworks : 1. Cognitive Behaviour Therapy
-

Goal:

Identify target symptoms

establish link between thoughts, feelings and actions
correct of misperceptions, irrational beliefs or reasoning biases

Required Skills:

self-monitoring of thoughts, feelings, and behaviour

alternate coping strategies

(Pilling et al., 2002)

FRIENDS: RESILIENCE
Theoretical Frameworks: 2. Resiliency Framework (Werner & Smith, 1992)

FRIENDS
Involves:

training manuals
FRIENDS trainer
teachers (1-day group-training sessions)
students (whole class, small group, individual)
parents

Lessons

10 sessions (+ 3 optional sessions for parents)

one-hour once a week
2 follow-up booster sessions (1 and 3 months after)

(FRIENDS can help, n.d.)

FRIENDS: OVERVIEW
Lessons (continued) (Ministry of Children and Family Development, n.d.)

FRIENDS: OVERVIEW
Lessons (continued) (Ministry of Children and Family Development, n.d.)

FRIENDS STRENGTH #1
Strength #1: FRIENDS is an evidence-based program that is
proven to be an effective tool for anxiety treatment
Based on the evidence, it is recognized by the World Health Organization (WHO) as the only evidencebased programme effective at all levels of intervention for anxiety in children (WHO, 2004)

Stallard et al. (2007):

Nurses were trained and supervised to deliver the program to children
The children were assessed 6 months before, when they started the program, and
3 months after they finished using self-report questionnaires for anxiety and selfesteem
Self-reports indicated decreased anxiety and increased self-esteem.

FRIENDS STRENGTH #1 (Contd)

Strength #1: FRIENDS is an evidence-based program that
is proven to be an effective tool for anxiety treatment
Lock & Barrett (2003)
Longitudinal, school-based study of grade 6-9 students from 7 different socioeconomic
diverse schools in Brisbane, Australia
General reductions in anxiety across time regardless of intervention condition
(FRIENDS and control condition)
Reductions were significantly greater in the FRIENDS program at both post-test and 12month follow up surveys (self-report measures of anxiety, depression, and coping)
Grade 6 showed significantly higher levels of anxiety than grade 9 at prior and post-test,
yet greater reduction in anxiety at 12 months (could suggest the optimal time for
preventing anxiety may be late childhood, around ages 9-10, rather than early
adolescence

FRIENDS STRENGTH #1 (Contd)

Strength #1: FRIENDS is an evidence-based program that
is proven to be an effective tool for anxiety treatment
Barrett et al. (2006)
Large sample size of youth from 737 schools, 669 students in grades 6 and 9.
Random assignment of 2 groups: treatment and control group
A reduction in anxiety and depression was found (more positive gains for grade 6 and
among girls rather than boys)
Results emphasized an important of early intervention.
Significant differences in anxiety were detected at 12 and 24 month follow ups (but not
at the 36 month follow up)

FRIENDS STRENGTH #1 (Contd)

Strength #1: FRIENDS is an evidence-based program that
is proven to be an effective tool for anxiety treatment
Shortt et al. (2001)
71 participants, ages 6.5 to 10 years old
Treatment included 10 FRIEND sessions + 2 booster sessions (after 1 & 3 months) run
by doctoral students
Compared to children on the waitlist, more children were diagnosis-free (69% v.s. 6%)
post-treatment, 68% still diagnosis free after 12 months using the Diagnostic Interview
Schedule for Children, Adolescents, and Parents (DISCAP)
More significant improvement on severity, according to parents and self-report
Significantly fewer children in the FRIENDS group being classified as high risk of an
emotional disorder at the 3-year follow-up (Barrett, Lock, & Farrel, 2005; Barrett at al.,
2006)

FRIENDS STRENGTH #2
Strength #2: FRIENDS is a school-based program
Why is a school-based program important?
Comparatively few children with significant emotional disorders receive interventions from specialist
child mental health services. (Ford, Goodman, & Meltzer, 2003)
Easy access: children typically lack the necessary means of independent transport needed to reach a
mental health unit. Referral barriers, cost barriers, lengthy waitlist, provide bidirectional access for
students to services and service providers to youth in need, especially for children with low SES, remote
communities (Ford, Goodman, & Meltzer, 2003)
Better to deal with attrition difficulties (Barrett et al., 2006)
Designed to fit elementary and high school curriculum, teachers can be trained to carry out this program
(McLoone, Hudson, & Rapee, 2006)
Can directly address issues of anxiety within school settings (i.e. separation anxiety from parents,
transition to a new school or higher grade, academic difficulties, etc.) (Rodgers & Dunsmuir, 2015)

FRIENDS STRENGTH #2 (Contd)

Strength #2: FRIENDS is a school-based program
Sponsored by the Ministry of Children and Family Development (MCFD) in B.C. for Health
Minds and Healthy People: 10 Year Plan to Address Mental Health and Substance Use in
B.C. (2010-2020) as a universal program for grades K to 7 (B.C. MCFD, 2015)
The Canadian Mental Health Association (CMHA) is using this program in partnership with
Fort McMurray Public School District for grades 4-6 (CMHA, 2015)
School-based trials indicate that students in the FRIENDS intervention group, compared to a
control group,report less anxiety symptoms post-treatment (75.3% drop of the cases in the
clinical group in comparison to 45.2% in the control group) (McLoone, Hudson, & Rapee,
2006)
Allows easier and faster access to the program when it can be delivered directly in the
classroom.

FRIENDS STRENGTH #3
Strength #3: FRIENDS is a universal program
The bulk of the universal intervention literature targeting child anxiety has been dominated by studies
of the FRIENDS program. (Lau & Rapee, 2011, p. 259)

FRIENDS Program can be implemented with a large group of children, even with those who
do not have problems with anxiety
Reaches a broad range of children and adolescents less chance of social stigmatization,
opportunities for peer support and modelling (McLoone, Hudson, & Rapee, 2006)
Removes the need for time-consuming screening and assessment processes by providing
access to everyone within an inclusive group setting (Lowry-Webster, Barrett, & Dadds, 2001)
Easier for teachers to manage an entire classroom when all of the students are completing a
universal program together (McLoone, Hudson, & Rapee, 2006)

FRIENDS STRENGTH #4
Strength #4: FRIENDS has been evaluated as a socially valid
program across different countries.
Social validity is a term coined by behavior analysts to refer to the social importance and
acceptability of treatment goals, procedures, and outcomes. (Foster & Mash, 1999, p. 308)
Essau, Conradt, & Ederer (2004)
studied the social validity of the German version of the FRIENDS Program that was implemented as a
universal prevention strategy for 208 children ages 9 to 12.
Children and their parents were highly satisfied with the program, according to the Spence Childrens
Anxiety Scale (SCAS) and the Depression subscale of the Revised Child Anxiety and Depression Scale
(RCADS)
Childrens attendance and completion of homework tasks were very high
Both children and parents rated the relaxation exercises and thinking helpful thoughts as the more
useful skills learned in the program
Significant correlation with treatment acceptability and childrens clinical outcome

FRIENDS STRENGTH #4 (Contd)

Strength #4: FRIENDS has been evaluated as a socially valid
program across different countries.
Cooper (2007)
FRIENDS Program was implemented among 29 grade 4 children ages 9 and 10 from a suburban
elementary school in Canada.
Social validity questionnaires were developed by the author to assess student perception weekly
Students reported that the program was easy to understand, that they enjoyed it, and it was helpful
90% completed all the homework activities, 85.7% would recommend it to others, and 71.4% thought it
was helpful.
Females gave higher ratings of enjoyment and program usefulness than males

FRIENDS STRENGTH #4 (Contd)

Strength #4: FRIENDS has been evaluated as a socially valid
program across different countries.
Gallegos-Guajardo, J., Ruvalcaba-Romero, N.A., Garza-Tamez, M., & Villegas-Guinea, D. (2013)
Completed the first social-validity evaluation the Spanish version of the FRIENDS Program with 498
Mexican children aged 9 to 11 in grades 4 and 5.
Children, parents, and teachers all filled out social validity questionnaires (developed by Barrett, 2005)
Parents and teachers gave high ratings towards program usefulness
Like Coopers findings, the children rated the relaxation techniques as the most helpful and girls
reported the program as more useful and enjoyable than boys.
Teachers questionnaire feedback stated that they learned how to enhance resilience in their students

FRIENDS STRENGTH #5
Strength #5: FRIENDS is acknowledged as an anxiety
prevention program that is beneficial across a variety of ages
(7-16 years old)
Prevention and early intervention is important in order to effectively treat children who may be at risk of
developing anxiety disorders (Lau & Rapee, 2011)
Rose, Miller, & Martinez (2009) acknowledged that the FRIENDS Program is an evidence-based CBT
approach to anxiety intervention/prevention programs
FRIENDS helps build emotional resilience and aims to reduce the incidence of serious psychological
disorders, emotional distress, and impairment in social functioning by teaching children how to cope with
and manage anxiety now and later in life (Rose, Miller, & Martinez, 2009)

FRIENDS STRENGTH #6
Strength #6: FRIENDS is a cost-effective program that involves
parents and teachers
Cost: Approximately $350, online facilitator workshops are available for $150 (The Friends Programs, 2015)
FRIENDS Program is universal where no screening process is needed, which saves time, money and
prevents children from being identified incorrectly (Lowry-Webster, Barrett, & Dadds, 2001)
Using the FRIENDS Program as a prevention tool to work against the development of anxiety disorders can
make it even more cost-effective by helping save on the cost of future treatment (Lau & Rapee, 2011)
Teachers and educators can be trained to implement this program, which can save on time and outside
facilitator costs.
There are teacher and parent resources available: www.friendsparentprogram.com
http://www.mcf.gov.bc.ca/mental_health/friends.htm

FRIENDS: QUESTIONS

Points to
consider.

FRIENDS: QUESTIONS TO PONDER

Question #1: Is a Universal program the best fit for to meet
your target needs?
Although there is research to indicate FRIENDS could be beneficial for all
students it is not always the best fit to meet the treatment needs of individual
high risk or already diagnosed children. (Maggin & Johnson, 2014; Davies et
al., 2011)
There is research to indicate that there is little impact due to the stigmatizing
of pull out programs and the small group format can be individualized to be
responsive to unique needs. (Horowitz & Garber, 2006; Rapee et.al., 2006)

FRIENDS: QUESTIONS TO PONDER

Question #2: Will you be able to implement FRIENDS and
maintain treatment fidelity?
Sawyers ( 2011) study noted problems with:
Teacher training
Resources
Setting

FRIENDS: QUESTIONS TO PONDER

Question # 3: Are you sure this is an Evidence Based
Program for your context?
Maggin & Johnson (2014) conducted a meta-analytical review of all
FRIENDS research prior to 2013. They had grave concerns regarding:
-Conceptual limitations of research design.
-Methodological limitations of research design.

FRIENDS: QUESTION #3 Continued

Maggin and Johnson found that when conceptual and
methodological limitations were considered FRIENDS did NOT have
the rigorous research required to be considered an Evidence Based
Program.
More is research in a school setting is needed to determine if
FRIENDS is as effective as it was previously reported to be.

FRIENDS: ANSWERS

Points to
consider.

FRIENDS: RESPONSE #1
Question #1: Is a Universal program the best fit for to meet
your target needs?
Shortt, Barrett, and Fox (2001)
Participants:
71 children ages 6.5 to 10 years with a diagnosis of GAD (n=42), Separation Anxiety
(n=19), and Social Phobia (n=10).
72% of children = comorbid anxiety disorders.
the Diagnostic Interview Schedule for Children, Adolescents and Parents
(DISCAP; Holland & Dadds, 1995) to confirm diagnosis - pre-, posttreatment and
follow-up
Assigned to either FRIENDS program or waitlist condition (10 week)

RESPONSE # 1 Continuted
Question #1: Is a Universal program the best fit for to meet
your target needs?
Shortt, Barrett, and Fox (2001)
Results:
Significant improvement in the FRIENDS group Vs. children in the waitlist group
Posttest: 69% of the FRIENDS groups diagnosis-free Vs. 6% in the waitlist group
12-month follow up: improvements were maintained a (68% still diagnosis-free)
Favorable treatment effects also found on self-report measures
Sheffield et al. (2006)
no significant differences in the effectiveness of the treatment of depression of 13-15
year olds using a universal, classroom-based, teacher approach vs. a small group,
intensive CBT intervention administered by mental health practitioners.

FRIENDS: RESPONSE # 2
Question #2: Will you be able to implement FRIENDS and
maintain treatment fidelity?
School-based programs relying on trained professionals is generally less sustainable
The FRIENDS program requires a 1-day standardized teacher-training workshop
School Districts in BC has one Professional Development day per month
Systematic review study: effect size of teacher run programs was slightly smaller
compared to programs employing other professionals (e.g., mental health
professional)
Finding also true for other anxiety intervention programs (Neil & Christensen, 2009)
Still 6 different studies which utilized teachers as program leaders found significant
improvements (Barrett & Turner, 2001; Barrett et al., 2005, 2006; Lock & Barret, 2003; Lowry-Webster et al., 2001, 2003)

RESPONSE QUESTION # 2 continued

Question #2: Will you be able to implement FRIENDS and
maintain treatment fidelity?
No or little research conducted on treatment fidelity.
Standardized Training
BC example
FRIENDS program launched provincially in 2004 and funded by a Ministry of
Children and Family Development (training, program materials, and student
workbook)
Currently included in the provinces 10-year plan to address mental health issue
in BC

(British Columbia Ministry of Children and Family Development, 2014)

Response to Question #3 FRIENDS

Question # 3: Are you sure this is an Evidence Based
Program for your context?
Fisak, Richard, & Mann (2011) completed a comprehensive, meta-analytic review
of the effectiveness of child and adolescent anxiety prevention programs. A total
of 31 articles were reviewed that identified anxiety prevention studies from 1970 to
2009.
A substantial number of studies identified in this review utilized the FRIENDS Program and it is
apparent that it is a particularly well-established and effective program for the prevention of
general anxiety symptoms (Fisak, Richard, & Mann, 2011)
Studies utilizing the FRIENDS Program were found to be more effective than programs that did
not use it (Fisak, Richard, & Mann, 2011)
In summary, Barretts manualized FRIENDS Program has received particularly strong and
consistent support (Fisak, Richard, & Mann, 2011)

Response to Question #3 FRIENDS (Contd)

Question # 3: Are you sure this is an Evidence Based Program
for your context?
The programs founder, Dr. Paula Barrett published the worlds first family treatment randomized
control trial for childhood anxiety in 1996. She and her research team have since been credited with
publishing more controlled trials for childhood anxiety than any other group in the world. (Barrett &
May, 2007, p. 7)
A comprehensive list of 25 years of research and evaluation articles, including independent replication
studies, are listed here: http://friendsprograms.com/research-articles/
FRIENDS is the only childhood anxiety prevention and treatment program acknowledged by the WHO
for its more than 12 years of comprehensive validation and assessment across several countries and
languages using rigorous randomized control studies. (Barrett & May, 2007, p. 7)

REFERENCES
Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. (2006). Long-term outcomes of
an Australian universal prevention trial of anxiety and depression symptoms in children and youth: an evaluation of the
friends program. Journal of clinical child and adolescent psychology, 35(3), 403-411. doi:10.1207/s15374424jccp3503_5
Barrett, P. & May, (2007). FRIENDS for Life: Introduction to FRIENDS. Brisbane,
Australia: Pathways Health and Research Centre.
Barrett, P. M., Lock, S., & Farrell, L. J. (2005). Developmental differences in universal
preventive intervention for child anxiety. Clinical Child Psychology and Psychiatry, 10(4), 539-555. doi:10.1375/bech.
20.4.183.29383
Barrett, P., & Turner, C. (2001). Prevention of anxiety symptoms in primary school
children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40(4), 399-410. doi:
10.1348/014466501163887
Briesch, A.M., Hagermoser Sanetti, L.M., Briesch, J. M. (2010). Reducing the prevalence of anxiety in children and adolescents: An
evaluation of the evidence base for the FRIENDS for life program. School Mental Health, 2(4), 155-165. doi.10.1007/
is12310-010-9042-5
British Columbia Ministry of Children and Family Development. (n.d.). Retrieved rom
http://www.mcf.gov.bc.ca/mental_health/pdf/friends_overview.pdf

REFERENCES
British Columbia Ministry of Children and Family Development. (2014). FRIENDS for life: Liaison manual. Ministy of Children
and Family Development. Retrieved from http://www.mcf.gov.bc.ca/mental_health/pdf/friends_liaison_manual.pdf
British Columbia Ministry of Child and Family Development (2015). B.C. Friends for Life. Retrieved from:
http://www.mcf.gov.bc.ca/mental_health/friends.htm.
Burstein, M., Georgiades, K., He, J. P., Schmitz, A., Feig, E., Khazanov, G. K., & Merikangas, K. (2012). Specific phobia among
US adolescents: Phenomenology and typology. Depression and anxiety, 29(12), 1072-1082. doi:10.1002/da.22008
California Evidence-Based Clearing House for Child Welfare (2015). Cool Kids Program. Retrieved from:
http://www.cebc4cw.org/program/cool-kids/detailed
Canadian Mental Health Association Northeast (2015). Friends for Life Program. Retrieved from:
http://woodbuffalo.cmha.ca/programs_services/friends-for-life-program/#.VWqgLEvfYfE.
Chalfant, A., & Rapee, R. M. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A
controlled trial. Journal of Autism and Developmental Disorders, 37, 1842-1857.
Cooper, J. (2007). Canadian Social Validity Evaluation of the FRIENDS School-Based Universal Anxiety Prevention Program.
(Masters thesis, University of Manitoba, Canada). Retrieved from: http://umanitoba.ca/graduate_studies/

REFERENCES
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in
childhood and adolescence. Archives of general psychiatry, 60(8), 837-844. doi:10.1001/archpsyc.60.8.837
Davies, M. (2011). Anxiety in children: Remote area sensitivities and considered changes in structuring a cool kids approach.
Australasian Psychiatry, 19(S1), S23-S25. doi:10.3109/10398562.2011.583055
Davis, T.E., May, A & Whtiing, S. E. (2011). Evidence-based treatment of anxiety and phobia in children and adolescents: Current
status and effects on the emotional response. Clinical Psychology Review, 31 (4), 592-602. doi:10.1016/j.cpr.2011.01.001
Essau, C.A., Conradt, J., & Ederer, E.M. (2004). Anxiety prevention among school children, Versicherungmedizin, 56(3),
123-130.
Ford, T., Goodman, R., & Meltzer, H. (2003). The British child and adolescent mental health survey 1999: the prevalence of
DSM-IV disorders. Journal of the American academy of child & adolescent psychiatry, 42(10),
1203-1211.doi:10.1097/00004583-200310000-00011
Foster, S.L. & Mash, E.J. (1999). Assessing social validity in clinical treatment resarch issues and procedures. Journal of
Consulting and Clinical Psychology, 67(3). 308-319.
FRIENDS can help. (n.d.). Retrieved from http://friendsrt.com/Content/Uploads/Documents/FRIENDS_Program_Brochure_e.pdf

REFERENCES
Gallegos-Guajardo, J., Ruvalcaba-Romero, N.A., Garza-Tamez, M., & Villegas-Guinea, D. (2013). Social validity evaluation of
the FRIENDS for life program with mexican children. Journal of Education and Training Studies, 1(1), 158-169. doi:
10.11114/jets.vlil.90
Henefer, J. & Rodgers, A. (2013). FRIENDS for Life: A School-based Positive Mental Health Programme. Research Project
Overview and Findings. Retrieved from http://www.nbss. ie/sites/default/files/friends_report_final_lr.pdf
Hudson, J. L., Rapee, R. M., Deveney, C., Schniering, C.A., Lynham, H. J., & Bocopoulos, N. (2008). Cognitive-behavioral
treatment versus an active control for children and adolescents with anxiety disorders: A randomized trial. Journal of
American Academy of Child and Adolescent Psychiatry, 48(5), 533-544.
Johnson, A. H. & Maggin, D. M. (2014). A meta-analytic evaluation of the FRIENDS program for preventing anxiety in student
populations. Education and treatment of children, 32(2), 277. doi: 10.1353/etc.2014.0018 Lau, E.X. & Rapee, R.M. (2011).
Prevention of anxiety disorders. Current Psychiatry Reports, 13(4), 258-266. doi:10.1007/s11920-011-0199-x
Lau, E.X. & Rapee, R. M. (2003). Prevention of anxiety disorders. Current Psychiatry Reports, 13(4), 258-266. doi:
10.1007/s11920-011-0199-x.
Lock, S., & Barrett, P. M. (2003). A longitudinal study of developmental differences in universal preventive intervention for child
anxiety. Behaviour Change, 20(04), 183-199. doi:10.1375/bech.20.4.183.29383

REFERENCES
Lowry-Webster, H.M., Barrett, P.M., & Dadds, M.R. (2001). A universal prevention trial of anxiety and depressive
symptomatology in childhood: Preliminary data from an australian study. Behaviour Change, 18, 36-50.
Lowry-Webster, H. M., Barrett, P. M., & Lock, S. (2003). A universal prevention trial of anxiety symptomology during childhood:
Results at 1-year follow-up.Behaviour change, 20(01), 25-43. doi:10.1375/bech.20.1.25.24843
Macquire University, Centre for Emotional Health. (2015). In Cool Kids for ASD: Child Anxiety Treatment (Ages 7-12yrs), from
http://www.centreforemotionalhealth.com.au/files/documents/Brochures/2015/Cool%20Kids%20ASD%20Program
%20Flyer_2015_BC0472_Approved_RD.pdf
Martinez, Y., Miller, L. & Rose, H. (2009). FRIENDS for life: the results of a resilience-building, anxiety- prevention program in a
Canadian elementary school. Professional school counselling, 12(6), 400.
McLoone, J., Hudson, J. L., & Rapee, R. M. (2006). Treating anxiety disorders in a school setting. Education and Treatment of
Children [H.W. Wilson - EDUC], 29(2), 219.
Neil, A. L., & Christensen, H. (2009). Efficacy and effectiveness of school-based prevention and early intervention programs for anxiety.
Clinical psychology review, 29(3), 208-215. doi:10.1016/j.cpr.2009.01.002
Pahl, K. M., & Barrett, P. M. (2007). The development of social-emotional competence in preschool-aged children: An introduction to the
Fun FRIENDS program. Australian Journal of Guidance and Counselling, 17(1), 81. doi:10.1375/ajgc.17.1.81

REFERENCES
Pearson, C., Janz, T., & Ali, J. (2013). Mental and substance use disorders in Canada. Statistics Canada. Retrieved from
http://www.statcan.gc.ca/pub/82-624-x/2013001/article/11855-eng.pd
Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., & Morgan, C. (2002). Psychological treatments in schizophrenia:
I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological medicine,32(05), 763-782. doi:10.1017/
S0033291702005640
Public Health Agency of Canada. (2011). The chief public health officers report on the state of public health in Canada, 2011. Public Health
Agency of Canada. Retrieved from http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2011/cphorsphc-respcacsp-06-eng.php
Rapee, R. M. (2000). Group treatment of children with anxiety disorders: Outcome and predictors of treatment response.
Australian Journal of Psychology, 52(3), 125-129.
Rapee, R. M., Abbott, M. J., & Lyneham, H. J. (2006). Bibliotherapy for children with anxiety disorders using written materials for parents:
A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444.
Rodgers, A. & Dunsmuir, S. (2015). A controlled evaluation of the FRIENDS for life emotional resiliency programme on overall anxiety
levels, anxiety subtype levels and school adjustment. Child and Adolescent Mental Health, 20(1), p. 13-19. doi:10.1111/camh.12030

REFERENCES
Rose, H., Miller, L., & Martinez, Y. (2009). FRIENDS for life: The results of a resilience-building, anxiety-prevention program in a
canadian elementary school. Professional School Counseling, 12(6), 400-407.
Sawyer, K. A. (2011). A qualitative study on the implementation of the FRIENDS anxiety management and mental health promotion
program. (Masters thesis, Trinity Western University.) Retrieved from https://www2.twu.ca/cpsy/theses/sawyerkafui.pdf
Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the FRIENDS program: A cognitive-behavioral group treatment for anxious
children and their parents. Journal of Clinical Child Psychology, 30(4), 525-535. doi:10.1207/S15374424JCCP3004_09
Stallard, P., Simpson, N., Anderson, S., Hibbert, S., & Osborn, C. (2007). The FRIENDS emotional health programme: Initial findings from a
school-basd project. Child and Adolescent Mental Health, 12(1), 32-37.
Statistics Canada. (2009). 2006 Census of Canada topic based tabulations, immigration and citizenship tables: Immigrant status and place
of birth of respondent, sex, and age groups, for population, for census metropolitan areas, tracted census agglomerations and
census tracts, 2006 census.(Catalogue number 92-565-xwe). Retrieved May 25, 2015 from Statistics Canada:
http://www12.statcan.gc.ca/census-recensement/2006/ref/preview-avantgout/pdf/812x11-eng.pdf
The Friends Programs (2015). The Friends Programs International Foundation Pty Ltd. Retrieved from: http://friendsprograms.com.

REFERENCES
Visser, V.S., Comans, T.A., & Scuffham, P.A. (2014). Evaluation of the effectiveness of a community-based crisis intervention program for
people bereaved by suicide. Journal of Community Psychology, 42(1), 19-28. doi:10.1002/jcop.21586
Wuthrich, V.M.., Rapee, R.M., Cunningham, M.J., Lyneham, H.J., Hudson, J.L., & Schniering, C.A. (2012). A Randomized
Controlled Trial of the Cool Teens CD-ROM Computerized Program for Adolescent Anxiety. Journal of the American
Academy of Child & Adolescent Psychiatry, 51(3), Retrieved from
http://ac.els-cdn.com.ezproxy.lib.ucalgary.ca/S0890856711010999/1-s2.0S0890856711010999-main.pdf?_tid=6609bfe6-02e2-11e5-936a-00000aacb361&acdnat=1432560890_bdc114fe27ee47f
636e92d3380125410