Santesteban-Echarrietal. 2018 BriefCopingCat Acceptedversion

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/325532554
Adapting the Brief Coping Cat for children with anxiety to a group setting
in the Spanish public mental health system: A hybrid effectiveness-
implementation pilot study
Article in Journal of Child and Family Studies · June 2018

DOI: 10.1007/s10826-018-1154-9
CITATIONS READS
0 125
7 authors, including:
Olga Santesteban-Echarri Simon M Rice

The University of Calgary University of Melbourne
29 PUBLICATIONS 20 CITATIONS 94 PUBLICATIONS 441 CITATIONS
SEE PROFILE SEE PROFILE
maria jose Güerre María Serrano Villar

hospital doce de octubre madrid Hospital Universitario La Paz
2 PUBLICATIONS 0 CITATIONS 6 PUBLICATIONS 5 CITATIONS
SEE PROFILE SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Clinical high-risk (CHR) for psychosis View project
Canine psychotherapy View project
All content following this page was uploaded by Olga Santesteban-Echarri on 13 June 2018.
The user has requested enhancement of the downloaded file.

Journal of Child and Family Studies
https://doi.org/10.1007/s10826-018-1154-9
ORIGINAL PAPER
1
2 Adapting the Brief Coping Cat to a Group Setting in the Spanish

3 Public Mental Health System: a Hybrid Effectiveness-Implementation
4 Pilot Study
5 Olga Santesteban-Echarri1,2 Laura Hernández-Arroyo1 Simon M. Rice3,4 M. José Güerre-Lobera1
● ● ● ●
6 María Serrano-Villar5 José Carlos Espín-Jaime1 Miguel Ángel Jiménez-Arriero1

● ●
7
8 © Springer Science+Business Media, LLC, part of Springer Nature
9 Abstract
10 Group therapy may offer a promising solution to reducing patient waiting lists for publicly funded mental health services. In
11 this study, an individual brief cognitive behavioral therapy (BCBT) intervention was adapted for implementation in a group
12 setting in the Spanish public mental health care system. The study was designed to test initial clinical effectiveness,
1234567890();,:
1234567890();,:
13 acceptability, and feasibility of the group adaptation of BCBT for child anxiety. The study utilized an uncontrolled multiple-
14 group design for 8 weeks (1 h per week). Inclusion criteria were (i) children and young adolescents between 8 and 15 years
15 old, and (ii) a clinical diagnosis of general anxiety disorder, social phobia, and/or separation anxiety disorder. Five groups
F
16 were completed (n = 33; mean age = 11 years; 42.4% females). A total of 31 (93.9%) participants completed at least
7 sessions, and follow-up data were collected for 84.9% (n = 28) of participants. Overall, anxiety symptoms were reduced
O
17
18 after intervention on the Spence Children Anxiety Scale, Generalized Anxiety Disorder Questionnaire-IV, Social Anxiety
O
19 Scale for Children-Revised, and Separation Anxiety Symptom Inventory. Our findings suggest that group BCBT was
20 associated with beneficial treatment outcomes, was acceptable and feasible for children with anxiety in the Spanish public
PR
21 mental health system. Both participants and their caregivers reported satisfaction and feelings of safety with the intervention.
22 Results underscore the need for a larger-scale hybrid effectiveness-implementation trial of BCBT in a group setting
23 throughout more community mental health centers in different Spanish states. Such work could improve patient access to
24 and benefit from an evidence-based treatment that works in community settings.
D
25 Keywords Anxiety Brief cognitive-behavioral therapy Exposure Coping cat Generalized anxiety disorder Separation
● ● ● ● ●
TE
26 anxiety disorder Social phobia

●
EC
Introduction 27
R
Anxiety disorders are the most prevalent disorders among 28

children and adolescents (Kessler et al. 2005; Merikangas 29
R
et al. 2010). Anxiety disorders occur early in life, with the 30

onset of 50% of cases established by age six (Merikangas
O
31
* Olga Santesteban-Echarri
olga.santesteban@gmail.com et al. 2010). Within anxiety disorders, generalized anxiety 32
C
disorder (GAD) is the most prevalent child disorder in 33

1
Hospital Universitario 12 de Octubre, Madrid, Spain clinical contexts, especially among older U.S. children and 34
N
2
Facultad de Ciencias de la Salud, Universidad Internacional de la young adolescents, followed by separation anxiety disorder 35
Rioja (UNIR), Madrid, Spain (SAD) among younger children (Kessler Petukhova et al.
U
36
3
Orygen, The National Centre of Excellence in Youth Mental 2012). Although less prevalent among children, social 37
Health, Melbourne, VIC, Australia phobia (SP) is more prominent during adolescence and is 38
4
Centre for Youth Mental Health, The University of Melbourne, associated with more severe impairment (Burstein et al. 39
Melbourne, VIC, Australia 2011). Within community samples, the estimated pre- 40
5
Instituto Psiquiátrico José Germain de Leganes, Madrid, Spain valence rate for adolescent anxiety disorders is 32% and is 41
42 usually higher among females (Merikangas et al. 2010). In clinical practice needs (Beidas et al. 2013; Crawley et al. 95
43 Spain, anxiety prevalence rates are similar, ranging from 17 2013). 96
44 to 26% (Ezpeleta et al. 2007; Fernández Aláez et al. 2000). Child CBT for anxiety usually comprises (i) a phase of 97
45 Anxiety disorders are associated with significant suffer- psychoeducation; (ii) skill training in affect recognition, 98
46 ing, affecting children’s functioning across social (i.e., relaxation, cognitive restructuring, and problem solving; 99
47 lower self-image, fewer friends, peer relation difficulties, and (iii) exposure (Crawley et al. 2013; Damschroder et al. 100
48 increased loneliness; Muroff et al. 2011; Settipani and 2009). Within the Brief Coping Cat, the authors excluded 101
49 Kendall 2013), familial (i.e., more conflict and commu- those mechanisms considered less effective in creating 102
50 nication difficulties with siblings and parents; Drake and therapeutic change (i.e., progressive muscle relaxation 103
51 Ginsburg 2012; Rapee 2012), and school (i.e., less atten- training) as preliminary results reported that a shorter 104
52 dance, performance and classroom participation; Mychai- intervention was effective in reducing anxiety without these 105
53 lyszyn et al. 2010; Nail et al. 2015) domains. When starting components (Hudson 2005; Rapee 2000). 106
54 in childhood, the presence of an anxiety disorder increases Despite the high prevalence rates, the early onset, high 107
55 the odds of a subsequent psychiatric disorder as an adult, rate of comorbidities with other disorders, along with 108
56 such as anxiety, depression, substance abuse disorders, and evidence-based programs showing effective at reducing 109
57 suicide attempts (Beesdo et al. 2007; Bittner et al. 2007; anxiety, children and adolescents with anxiety are the least 110
58 Boden et al. 2007; Gregory et al. 2007; Pine et al. 1998), likely to receive treatment relative to other disorders (i.e., 111
59 especially if not treated (Weissman et al. 1999). ADHD, oppositional defiant disorder, or conduct disorder), 112
60 Meta-analyses and reviews on randomized controlled with only 41.4% of those with a need for care treated in the 113
61 trials (RCTs) have established the efficacy of cognitive U.S. (Costello et al. 2014). Similarly, in Spain, there are 114
62 behavior therapy (CBT) among different therapeutic challenges to accessing intensive treatment services within 115
63 approaches for child anxiety disorders (Cartwright-Hatton public mental health system, characterized by long waiting 116
64 et al. 2004; In-Albon and Schneider 2006). In particular, it lists and scarce accessibility for children with more severe 117
F
65 has been suggested that among all the CBT components, anxiety disorders (Tizón García 2002). For example, the 118
O
66 participant modeling (i.e., learning vicariously through the mean ratio of child and adolescent psychologists within an 119
67 observation and guidance of a model), exposure, and outpatient facility in the Spanish public mental health sys- 120
O
68 practice with reinforcement components (Barlow 2002; tem (5.3 per 100,000 inhabitants; median of 4.5) varies 121
69 Feske and Chambless 1995) seem to be the most effective according to community, ranging from 2.2 in Extremadura 122
PR
70 techniques to treat anxiety, including social phobia. to a 14.1 in Cataluña (Cátedra de Psiquiatría Infantil Fun- 123
71 Other variables, such as parental factors, also have an dación Alicia Koplowitz 2014). These figures are lower 124
72 important role in the development, maintenance, and reci- than both other comparable European countries, as well as 125
procal influence of child anxiety disorders (Rapee 2012). the recommended ratio for providing adequate services
D
73 126
74 Thus, the majority of the recommended interventions to (Remschmidt and Engeland 1999). Knowing that childhood 127
TE
75 treat child anxiety problems include some parental sessions. and early adolescence are critical periods for early inter- 128
76 Among those, the Coping Cat (full version; Kendall and vention, this situation underscores that current mental health 129
77 Hedtke 2006) has been proven to reduce anxiety in RCTs of resources for children and adolescents in Spain are 130
EC
78 individual treatment (16 sessions; Kendall et al. 1997; insufficient. 131

79 Kendall et al. 2008; Walkup et al. 2008), and group treat- Given resource constraints within the public system, 132
80 ment (18 sessions; Flannery-Schroeder and Kendall 2000; group interventions could be a promising format to over- 133
R
81 Flannery-Schroeder et al. 2005). Moreover, the manual of come setting difficulties. Moreover, group interventions 134
82 the individual version of the Coping Cat has been translated offer unique advantages over individual therapy (i.e., peer 135
R
83 to Spanish, known as “El Gato Valiente” (Kendall and modeling, peer reinforcement and group feedback to iden- 136
Kosovsky 2010a, 2010b). Nevertheless, despite the evi- tify, challenge and offer alternatives to negative thoughts
O
84 137
85 dence supporting the use of the Coping Cat CBT inter- and defeatist beliefs; Flannery-Schroeder and Kendall 138
C
86 vention for child and adolescent anxiety, there is a 2000). Because participants from a group may share a 139
87 disconnection between clinical practice possibilities and similar age, experiences, and common symptoms, children 140
N
88 empirically validated interventions. For example, it seems place greater credibility on other participants’ support and 141
that there have been difficulties in implementing and dis- advice (Santesteban-Echarri et al. 2017). Interestingly, it
U
89 142
90 seminating the original Coping Cat intervention in a com- seems from meta-analyses that there are no group differ- 143
91 munity setting due to the length of the program (Beidas ences of clinical results between those receiving group 144
92 et al. 2012; Beidas and Kendall 2010). Therefore, a shorter treatment versus individual treatment of childhood anxiety 145
93 version, the Brief Coping Cat CBT (eight individual ses- (Flannery-Schroeder and Kendall 2000; In-Albon and 146
94 sions), was developed as a response to real-world Schneider 2006; Liber et al. 2008; Manassis et al. 2002; 147
148 Muris et al. 2001). In particular, group therapy using the symptoms. Feasibility was assessed by clinical service 201
149 Coping Cat showed a moderate to large effect (d = feedback of the intervention implementation in the clinical 202
150 0.59–2.09) in reducing anxiety symptoms up to remission in context (i.e., barriers, difficulties). In addition, attendance 203
151 a single-group study (de Souza et al. 2013). Group therapy was evaluated by number of sessions attended by children 204
152 using the Coping Cat has also been compared to individual and their parents (i.e., completing at least 6 out of 8 ses- 205
153 therapy (Flannery-Schroeder and Kendall 2000) showing sions: i.e., 75% of attendance for children, and at least one 206
154 promising results. Both the individual and group conditions caregiver attending the two parent sessions). Finally, safety 207
155 showed that >50% of the participants did not meet diag- was indicated by (i) children reporting feeling supported by 208
156 nostic criteria of a primary anxiety disorder after treatment, therapists, measured via a treatment satisfaction ques- 209
157 with no significant differences between conditions. Partici- tionnaire; and (ii) all children perceiving the group to be 210
158 pants in the group condition performed better than the safe. 211
159 individual condition in reducing the severity of any anxiety
160 disorder (GAD, SAD, or SP). These results were maintained
161 without significant differences among groups at the 3- Methods 212
162 month follow-up. Given this, choice of therapy format may
163 be based on considerations such as referral rates, clinical Participants 213
164 resources, and personal preferences. Implementation of
165 group therapies within regular clinical practice may be a A total of 37 referrals were received from practising child 214
166 cost-effective alternative to reach and provide treatment psychologists or psychiatrists from the Villaverde and 215
167 from specialized child and adolescent services to a larger Carabanchel areas during 2015 and 2016 (Psychiatry and 216
168 population (Flannery-Schroeder and Kendall 2000; Mental Health Clinical Management Area from the Hospital 217
169 Flannery-Schroeder et al. 2005). Moreover, the group for- Universitario 12 de Octubre, Madrid, Spain). All referrals 218
170 mat may improve long-term engagement with child and were assessed on the basis of a principal anxiety disorder. 219
F
171 adolescent services and treatment generalization to other Of these, three referrals were deemed as ineligible after 220
O
172 settings because group interventions provide a therapeutic reading the referral notes and medical histories due to 221
173 context representative of daily situations in which general- comorbidity and erroneous diagnostic category. Moreover, 222
O
174 ization is desired (i.e., at school, with peers, in social one referral did not meet inclusion criteria after assessment 223
175 situations; Kendall and Zupan 1981; Manassis et al. 2002). (presenting separation anxiety symptoms were better 224
PR
176 To sum up, presenting with an anxiety disorder during explained by post-traumatic stress disorder). Thirty-three 225
177 childhood is a potential vulnerability indicator for an adult families consented to participate; therefore, 33 children 226
178 mental health disorder, especially if left untreated. completed the intervention induction and started a group 227
Accordingly, the Spanish public mental health system needs (each group was designed for between five and six chil-
D
179 228
180 to prioritize offering cost-effective therapies that are dren). Two participants dropped out from the groups, 229
TE
181 empirically validated to reduce child anxiety. We are not leaving 31 children who completed all the sessions. The 230
182 aware of any studies reporting implementation of the Brief post-intervention assessment was completed by 28 231
183 Coping Cat, at the group level, in a public health setting. participants. 232
EC
184 The present study was designed as an effectiveness- Inclusion criteria were adapted to reflect the original 233
185 implementation hybrid type 1 study (Curran et al. 2012), Brief Coping Cat study criteria (Beidas et al. 2013; Crawley 234
186 which aimed to simultaneously test a clinical intervention et al. 2013): (i) children and young adolescents between 8 235
R
187 and gather information on its delivery in a clinical context and 15 years old inclusive; (ii) a clinical diagnosis based on 236
188 (as compared to a research context). Therefore, the objec- referral notes of generalized anxiety disorder (GAD), social 237
R
189 tive of this study was to test effectiveness outcomes (i.e., phobia (SP), and/or separation anxiety disorder (SAD) 238
clinical outcomes) and implementation outcomes (i.e., using the Diagnostic and Statistical Manual of Mental
O
190 239
191 acceptability and feasibility) of a group adaptation of the Disorders-IV (DSM-IV; American Psychiatric Association 240
C
192 individual Brief Coping Cat (Beidas et al. 2013; Crawley 2000), or the Classification of Mental and Behavioral Dis- 241
193 et al. 2013). The target population was children and young orders (ICD-10; World Health Organization 1992) as 242
N
194 adolescents with an anxiety disorder in the Spanish public employed in the Spanish public mental health system; (iii) 243
mental health system who received 8 weeks of intervention ability to give informed consent and comply with study
U
195 244
196 participation. Acceptability of the intervention, measured by procedures for parents and assent from children; and (iv) 245
197 the perceived usefulness of the group intervention and family commitment to attend two parent sessions. Exclusion 246
198 perceived helpfulness provided by therapists, peers, and criteria were (i) intellectual disability, (ii) inability to con- 247
199 parents, was also assessed. Potential clinical benefits were verse or understand Spanish, and (iii) comorbid diagnosis of 248
200 assessed according to changes in self-reported anxiety conduct disorder as referred by treating clinician. 249
250 Procedure completed at home (i.e., to sleep alone, to stay in the dark or 300
to stay in a place without their parents). Two exposures 301
251 The study utilized an uncontrolled multiple-group design. were undertaken as a group (i.e., a surprise exam and a 302
252 Ethical approval for the project was received by the Hos- presentation of a story in front of an unfamiliar audience for 303
253 pital Universitario 12 de Octubre Research Ethics Com- them; for detailed description of the sessions, see 304
254 mittee. Participants were recruited over an eighteen-month Santesteban-Echarri et al. 2015. 305
255 period (April 2015–September 2016). Referrals from treat- As a note, it should be clarified that during the inter- 306
256 ing clinicians were received, upon which an independent vention phase, families did not have their regular appoint- 307
257 clinician obtained consent to participate. The average wait ments with their child and adolescent clinician unless 308
258 time between when participants were contacted and the strictly necessary (none was needed). In the Spanish public 309
259 induction session was 2 weeks. In the induction session, health care system, the frequency of this intervention is 310
260 information regarding the group was given to participating considered intensive compared to the usual frequency of 311
261 children and an initial baseline assessment was conducted. appointment for anxiety disorders (range: one visit each 312
262 Moreover, parents were given a space to share their con- 1–2 months). 313
263 cerns and their child’s difficulties. Questionnaires for the
264 parents to complete at home were provided in this induction Measures 314
265 session. As soon as there was at least a group of five chil-
266 dren assessed, they were offered an eight-session group and Questionnaires Administered to the Children 315
267 an extra assessment session post-group. When there were
268 enough referrals to form a new group, a new eight-session All questionnaires were administered to children both at 316
269 intervention was offered. Therefore, a total of five groups pre- and post-intervention with the exception of the children 317
270 were conducted over the study period. Children were fears (pre-intervention only) and the satisfaction ques- 318
271 grouped relating their age, trying to organize homogeneous tionnaire (post-intervention only). Satisfactory internal 319
F
272 groups in terms of developmental stage (for detailed infor- consistency was met by all standardized scales. 320
O
273 mation of the design, procedure and materials, see
274 Santesteban-Echarri et al. 2015). Child Anxiety 321
O
275 Throughout the intervention period, therapists invited
276 parents to follow up as needed (waiting in the waiting room Child anxiety was measured with the Spanish version of the 322
PR
277 while the group took place). Moreover, therapists partici- Spence Children Anxiety Scale, SCAS; (Godoy et al. 2011; 323
278 pated in clinical meetings with the clinical team and had the Spence 1997), a 38-item scale with a 4-point Likert scale 324
279 opportunity to discuss any issue pertaining to any of responses type (1 = “never,” 2 = “sometimes,” 3 = “often,” 325
the children of the group with their treating clinician. 4 = “always”). The measure comprises six subscales:
D
280 326
281 The participants and their caregivers were assessed separation anxiety (six items, i.e., “I worry when I am away 327
TE
282 pre-intervention and post-intervention (within 2 weeks from my parents”); social phobia (six items; i.e., “I am 328
283 after completion the group) on the outcomes described afraid to have to talk in front of my classmates”); obsessive- 329
284 below. compulsive disorder (6 items, i.e., “I have to do some things 330
EC
in a certain way to prevent bad things from happening”); 331

285 Intervention panic/agoraphobia (nine items, i.e., “Sometimes I feel as if I 332
can not breathe”); physical injury fears (i.e., “I am afraid to 333
R
286 We adapted the individual Spanish version of a brief cog- go to the doctor or dentist”); and generalized anxiety (six 334
287 nitive behavioral therapy (BCBT), the Brief Coping Cat items, i.e., “I worry that something bad can happen to me”). 335
R
288 (Beidas et al. 2013; Crawley et al. 2013) into a group setting Scores range from 0 to 114 (reliability: α = 0.92–0.94; 336
in the context of the Spanish public mental health system. convergent validity: r = 0.70–0.80).
O
289 337
290 Each group lasted 2 months (eight sessions of 1 h, once a
C
291 week). An experienced clinical psychologist and a co- Generalized Anxiety 338
292 therapist (trainee in 4th year of residency) conducted the
N
293 groups. Therapists were clinical staff from the hospital, and Generalized anxiety was measured with the Spanish version 339
groups were offered as part of the usual clinical care of the of the Generalized Anxiety Disorder Questionnaire-IV,
U
294 340
295 centre. Main components of the sessions were divided in GADQ-IV; (Newman et al. 2002; Sandín 1997), 12-item 341
296 two modules: (i) Module 1: comprising psychoeducation, questionnaire with items assessing general worries (i.e., “Do 342
297 functional analysis, cognitive restructuring and problem you think your worries are excessive?”) and physical 343
298 solving; and (ii) Module 2: comprising exposure tasks and symptoms (i.e., “When you worry, do you have muscle 344
299 positive reinforcement. Some exposure tasks had to be tension?”), with scores ranging from 0 to 12 (reliability: α 345
346 = 0.85; convergent validity: r = 0.45–0.66; Newman et al. (1 = “yes”; 0 = “no”) regarding their satisfaction with the 393
347 2002). length of the group (i.e., “Do you think eight sessions were 394
enough?”). 395
348 Social Anxiety
Questionnaires Administered to the Parents 396
349 Social anxiety was measured with the Spanish version of
350 the Social Anxiety Scale for Children-Revised, SASC-R; All questionnaires were administered to parents only at pre- 397
351 (La Greca and Stone 1993; Sandín 1997) an 18-item scale intervention, with the exception of the parental anxiety scale 398
352 with a 3-point Likert scale response type (1 = “never,” 2 (pre- and post-intervention), and the satisfaction ques- 399
353 = “sometimes,” 3 = “often”). The measure comprises three tionnaire (post-intervention only). 400
354 subscales: fear to negative evaluation (eight items, i.e., “I
355 worry about what others think of me”); avoidance/social Socio-Demographics 401
356 distress to new situations with equals (six items, i.e., “I get
357 nervous when I talk to new people”); and avoidance/social We used a structured interview created for the study. 402
358 distress-generalized (four items, i.e., “I feel shy even with Detailed information regarding demographics and family 403
359 people that I know very well”). Scores range from 18 to 54 and mental health background was asked. Socioeconomic 404
360 (reliability: α = 0.88–0.90; convergent validity: r = status (SES) was determined by the yearly median income 405
361 0.52–0.63; Storch et al. 2003). in Spain reported by the National Institute of Statistics in 406
2014 (i.e., €19,230) (Insituto Nacional de Estadistica 2014). 407
362 Separation Anxiety A categorical variable was created (0 = “below the median 408
salary,” 1 = “above the median salary”). A categorical 409
363 Separation anxiety was measured with the Spanish version variable was also created for mother and father education 410
364 of the Separation Anxiety Symptom Inventory, SASI; (0 = “≤high school”, 1 = “>high school”). 411
F
365 (Sandín 1997; Silove et al. 1993), a 15-item inventory (i.e.,
O
366 “I do not want to stay home alone”) with a 4-point Likert Parental Anxiety 412
367 scale response type (0 = “never,” 1 = “almost never,”
O
368 2 = “almost every time,” 3 = “every time”) and scores Parental anxiety was measured with the Spanish version of 413
369 ranging from 0 to 45 (reliability: α = 0.88; convergent the State-Trait Anxiety Index, STAI; (Buela-Casal et al. 414
PR
370 validity: r = 0.72–0.79; Silove et al. 1993). 2011; Spielberg 1973), a 40-item index (20 for each sub- 415
scale: state anxiety and trait anxiety) with a 4-point 416
371 Children’s Satisfaction Likert scale response type (1 = “nothing,” 2 = “rarely,” 3 417
= “sometimes,” 4 = “a lot”) and scores ranging from 0 to
D
418
372 Children’s satisfaction was measured with a questionnaire 60 for each subscale (reliability: α = 0.90 trait anxiety; α = 419
TE
373 comprising 21 items with a 0–10 continuous scale response 0.94 state anxiety; convergent validity: r = 0.73–0.85; 420
374 type (from 0 = “nothing” to 10 = “a lot”). This ques- Spielberger 1983). 421
375 tionnaire was developed for this study, and asked about the
EC
376 amount of perceived help by (a) the therapeutic content (i.e., Parental Report on Child’s Behaviors 422
377 “How much did it help to expose and practice the feared
378 situations, doing “the challenges”?”; “How much did it help Parental report on child’s behaviors was measured with the 423
R
379 to talk about and understand the negative thoughts?”); (b) Spanish version of the Child Behavior Checklist 4–16 for 424
380 their parents (i.e., “During the group, how much help do parents, CBCL; (Achenbach 1991; Albores-gallo et al. 425
R
381 you consider your parents gave you to overcome your dif- 2007). The CBCL comprises eight subscales (thought pro- 426
ficulties with your fears, worries and anxiety?”); (c) their blems, attention problems, social problems, withdrawn and
O
382 427
383 group peers (i.e., “How much did it help to realize that other depression, somatic complaints, anxiety and depression, 428
C
384 boys and girls had similar difficulties as the ones you rule-breaking behavior and aggressive behavior; reliability: 429
385 have?”); (d) therapists (i.e., “Was easy to understand the α = 0.97). See Ebesutani et al. (2010) for convergent 430
N
386 information the therapists were explaining?”; “If something validity of the CBCL subscales with the Diagnostic and 431
bad had happened during a session, did you feel that the Statistical Manual of Mental Disorders (DSM, American
U
387 432
388 therapist would have helped you?”); (e) general satisfaction Psychiatric Association 2000) diagnosis. Moreover, a 433
389 with the group (i.e., “If you knew another kid had diffi- CBCL-Anxiety specific subscale was developed following 434
390 culties similar to yours, how much would you recommend recommendations by Kendall et al. (2007) to provide better 435
391 him/her to come to this group?”; “In general, how much did concordance with other measures of anxiety than the CBCL 436
392 the group help you?”); and (f) three dichotomous questions internalizing and anxious/depressed subscales. Sixteen 437
438 items from the original scale (9, 11, 29, 30, 31, 32, 45, 46, household apart from the child was 2.9 (SD = 0.77) ranging 483
439 50, 56a, 56b, 56c, 56f, 71, 75, 112) were computed to create from 2 to 6 people. The majority of biological parents were 484
440 the new subscale. married and cohabiting (87.9%), 6.1% were cohabiting, and 485
6.1% were divorced and not cohabiting. Regarding parental 486
441 Parental Satisfaction education, 51.5% and 57.6% of mothers and fathers, 487
respectively, finished high school. Among those with higher 488
442 Overall parental satisfaction was measured with a ques- education, the majority undertook a vocational training 489
443 tionnaire comprising 14 items with a 0–10 continuous scale program (36.4% and 24.2% of mothers and fathers, 490
444 response type (from 0 = “nothing” to 10 = “a lot”) was respectively) and a minority of the parents finished uni- 491
445 developed for this study asking about (a) their knowledge of versity (12.1% and 18.2% of mothers and fathers, respec- 492
446 the content of the sessions (i.e., “Have you felt involved and tively). A third of the families were living below the median 493
447 knew the “challenges” your child had to face?”); (b) satis- income rate for Spain and only 21.3% made more than 494
448 faction regarding the parent sessions (i.e., “Did it help double income compared to the median for Spain. 495
449 hearing other parent’s commenting that their children had Pre-intervention, 14 (42.4%) children were diagnosed 496
450 similar difficulties than your child?”); (c) satisfaction with with a primary diagnosis of social anxiety, 15 (45.5%) with 497
451 the therapists (i.e., “Were the therapists available and GAD, and 4 (12.1%) with SAD. Relating clinical history, 498
452 approachable to ask questions and explanations?”; “Did you children were diagnosed with an anxiety disorder when they 499
453 feel comfortable with the therapists?”); and (d) general were an average of 9.2 years old (ranging from 3 to 14 years 500
454 satisfaction with the group and the perceived help for their old). A third of the families had visited a mental health 501
455 children (i.e., “In general, how much do you think the group specialist before, and 9.4% of the children were currently 502
456 has helped your child?”; “If you knew that another child has attending another specialist center and were taking medica- 503
457 difficulties similar to those of your child, how much would tion for anxiety problems. Finally, 65% of the parents 504
458 you recommend coming to this group?”). Moreover, three reported previous family history of anxiety disorders: 21.9% 505
F
459 dichotomous questions (1 = “yes”; 0 = “no”) were asked of biological fathers (6.3% diagnosed); 40.7% of biological 506
O
460 regarding the number/length of the sessions (i.e., “Do you mothers (18.8% diagnosed); 12.5% of siblings (6.2% diag- 507
461 think eight sessions were enough for your child?”; “Do you nosed); and 48.4% of other family members (16.1% diag- 508
O
462 think two parent sessions were enough?”). nosed) had previous histories of anxiety disorders. 509
Table 1 shows baseline differences in demographics and 510
PR
463 Data Analyses clinical variables by baseline diagnosis (social anxiety, GAD 511
and SAD). There were no significant differences between 512
464 Descriptive statistics and intervention acceptability and groups on demographic variables. However, there were 513
feasibility were established by means and frequency ratings. some differences in clinical symptoms. The SAD group had
D
465 514
466 Clinical benefit of the intervention (i.e., measure of statis- significantly higher scores in separation anxiety symptoms 515
TE
467 tical significance of the change between pre- and post- (measured both by the SCAS an SASI) and panic/agor- 516
468 intervention) were assessed through paired sample t-tests. aphobia symptoms compared to the social anxiety group. 517
469 Clinical significance of pre-post changes was assessed by Moreover, the GAD group had significantly higher scores in 518
EC
470 effect sizes (Cohen’s d). generalized anxiety symptoms than the social anxiety group. 519
However, these results should be interpreted with caution 520
due to the small sample size of each group. 521
R
471 Results
Effectiveness Outcomes 522
R
472 Descriptive Statistics

Clinical Variables—Children Report
O
523
473 Out of the 33 children who started a group, two participants
C
474 dropped out from the group, with 93.9% completing all the Table 2 shows differences between pre- and post- 524
475 sessions. Post-intervention assessment was completed by intervention results on the self-reported measures (n = 28). 525
N
476 84.9% (n = 28) of participants. The mean age at pre- There was an overall significant decrease in anxiety 526
intervention was 11 years (SD = 1.85) ranging between 8 symptoms (p < 0.05) after 8 weeks of intervention for the
U
477 527
478 and 15 years old, and 42.4% (n = 14) of the participants total scales (i.e., general anxiety, generalized anxiety, social 528
479 were girls. A total of 97% of participants were born in Spain anxiety, and separation anxiety). However, when examining 529
480 (only one participant was born in a non-Spanish speaking scores among subscales, there was no significant decrease 530
481 country), and 100% of participants were native Spanish on social phobia and fears from the SCAS scale, and the 531
482 speakers. The mean number of people living in the social anxiety distress and generalized distress subscales 532
Table 1 Baseline differences in

SP GAD SAD Test p Effect size
demographics and clinical
(n = 14) (n = 15) (n = 4) statistic
variables by baseline diagnosis
Demographics n (%) n (%) n (%) χ2 p Cramer’s V
Gender (male) 6 (42.9) 11 (73.3) 2 (50.0) 2.86 0.239 0.29

History of familial anxiety 3 (42.9) 4 (36.4) 1 (25.0) 0.35 0.839 0.13
Mother anxiety 3 (33.0) 3 (27.3) 0 (0.0) 1.70 0.428 0.27
Father anxiety 1 (11.1) 0 (0.0) 1 (25.0) 2.55 0.280 0.33
Previous contact with MH 5 (38.5) 4 (26.7) 1 (25.0) 0.53 0.766 0.13
SES (b.m.s.) 7 (53.9) 3 (20.0) 1 (33.3) 3.49 0.175 0.34
Mother education 7 (50.0) 7 (46.7) 3 (75.0) 1.04 0.595 0.18
(<high school)
Father education 9 (64.3) 8 (53.3) 2 (50.0) 0.46 0.794 0.12
(<high school)
M (SD) M (SD) M (SD) Fa p η2
Age 11.00 (2.2) 11.13 (1.6) 10.75 (1.7) 0.07 0.935 0.004
Clinical variables
SCAS total 35.3 (14.5) 36.3 (14.0) 62.0 (22.9) 5.60 0.061 0.27
Separation anxiety 6.2 (3.2)* 6.7 (3.5) 11.5 (3.7)* 6.62 0.037 0.22
Social phobia 7.2 (3.2) 5.8 (3.1) 7.5 (1.3) 1.96 0.376 0.07
OCD 5.9 (3.3) 5.5 (3.4) 9.3 (3.4) 3.95 0.139 0.12
Panic/agoraphobia 4.5 (3.7)* 6.5 (3.4) 14.3 (8.3)* 8.09 0.018 0.36
Fear 4.4 (3.3) 3.0 (2.1) 7.5 (4.8) 3.83 0.147 0.21
F
Generalized anxiety 7.3 (2.8) 8.8 (2.7) 12.0 (4.3) 5.27 0.072 0.21
O
GADQ-IV 5.6 (2.3)* 9.1 (1.1)* 8.9 (2.8) 14.67 0.001 0.46
SASC-R total 34.6 (6.7) 32.1 (5.1) 32.8 (1.7) 1.29 0.524 0.04
O
SASC-R FNE 16.2 (3.0) 14.8 (3.0) 16.0 (2.5) 1.77 0.413 0.06
SASC-R SAD 12.1 (3.2) 12.0 (2.3) 10.5 (2.5) 1.69 0.430 0.04
PR
SCAS-R SAD-G 6.3 (1.8) 5.3 (1.3) 6.3 (0.5) 3.20 0.202 0.10
SASI 14.8 (6.7)* 18.3 (7.0) 29.3 (6.7)* 9.72 0.008 0.32
N varies between variables due to missing data
D
SP social phobia, GAD generalized anxiety disorder, SAD separation anxiety disorder, MH mental health, Q1
SES socioeconomic status, b.m.s. below the median salary Q2
TE
*Indicates which groups differ

a
Independent-samples Kruskal–Wallis test; significance level is 0.05
EC
533 from the SASC-R scale. Sensitivity analyses were per- Additional alternative models were run excluding parti- 548
R
534 formed to assess differences in the change between pre- and cipants from the first group to take into account the protocol 549
535 post-intervention between diagnoses. Models were run changes that were implemented for the remaining four 550
R
536 stratifying the sample by baseline diagnosis (social anxiety, groups. We found a very similar pattern of results, although 551
GAD, and SAD). Table 3 shows that participants from the the SCAS-Fear subscale (Mpre = 3.8; SDpre = 3.0; Mpost
O
537 552
538 social anxiety group had a significant decrease in OCD = 3.1; SDpost = 3.3; t = 2.08; p = 0.050; d = 0.44) and the 553
C
539 symptoms (p = 0.048) and fear of negative evaluation (p = SAD-G subscale of the SASC-R (Mpre = 6.2; SDpre = 1.5; 554
540 0.020). Moreover, participants from the GAD group had a Mpost = 5.3; SDpost = 1.9; t = 2.46; p = 0.022; d = 0.50) 555
N
541 significant reduction in panic/agoraphobia symptoms (p = became significant (all results available upon request). 556
0.036), generalized anxiety symptoms (measured by the
U
542
543 SCAS and GADQ-IV; p’s = 0.024, 0.025 respectively) and Clinical Variables—Parent Report 557
544 separation anxiety (p = 0.018). There were no significant
545 decreases in symptoms for the SAD group; however, these Parents did agree in overall responses to the CBCL, giving 558
546 results should be interpreted with caution due to the small higher scores to their children’s internalizing symptoms. 559
547 sample size of each group. However, there was a discrepancy among informants for 560
Table 2 Change between pre-

Pre- Post-
intervention and post-
intervention intervention
intervention at 8th week for
clinical outcome variables for Variable M SD M SD Range measure t p d
participants completing
post-intervention assessment CASI 31.5 5.4 26.7 6.9 18–54 3.25 0.003 0.63
(n = 28)a SCAS total 35.5 13.9 27.4 13.9 0–114 2.97 0.007 0.58
Separation anxiety 6.3 3.1 4.7 2.6 0–18 2.16 0.040 0.42
Social phobia 6.2 3.0 5.5 2.8 0–18 1.67 0.108 0.32
OCD 5.5 2.8 4.3 2.8 0–18 2.31 0.029 0.44
Panic/agoraphobia 5.9 4.0 3.8 3.8 0–27 3.25 0.003 0.64
Fear 3.8 3.0 3.1 3.1 0–15 1.93 0.064 0.37
Generalized anxiety 8.0 2.9 6.4 2.7 0–18 2.59 0.015 0.50
GADQ-IV 7.2 2.5 5.9 2.7 0–12 2.64 0.014 0.50
SASC-R total 32.8 5.8 29.7 8.4 0–54 2.18 0.039 0.42
SASC-R FNE 15.4 3.1 13.3 3.6 0–24 2.58 0.016 0.50
SASC-R SAD 11.6 2.7 11.0 3.7 0–18 1.27 0.216 0.24
SCAS-R SAD-G 5.9 1.5 5.4 1.8 0–12 1.60 0.122 0.30
SASI 16.6 7.1 11.6 5.9 0–45 3.47 0.002 0.67
FSSC-R 147.5 25.1 — — 80–240 — —
N varies between variables due to missing data
CASI Childhood Anxiety Sensitivity Index for Children, SCAS Spence Children Anxiety Scale, OCD
obsessive-compulsive disorder, GADQ-IV Generalized Anxiety Disorder Questionnaire-IV, SASC-R Social
F
Anxiety Scale for Children-Revised, FNE fear to negative evaluation, SAD social anxiety distress, SAD-G
social anxiety distress-generalized, SASI Separation Anxiety Symptom Inventory, FSSC-R Fear Survey
O
Schedule for Children-Revised, M mean, d Cohen’s d, t t-test, p p-value
a
Number of cases for each variable varies slightly due to missing data
O
PR
Table 3 Change between pre-intervention and post-intervention at 8th week for clinical outcome variables for participants completing post-
intervention assessment by baseline diagnosis
Social phobia (n = 13) Generalized anxiety (n = 13) Separation anxiety (n = 3)
D
a a
Variable Mpre (SD) Mpost (SD) p Mpre (SD) Mpost (SD) p Mpre (SD) Mpost (SD) pa
TE
SCAS total 33.2 (14.8) 27.0 (17.7) 0.153 33.7 (12.3) 28.6 (10.3) 0.152 51.3 (10.0) 23.0 (18.2) 0.109
Separation anxiety 6.0 (3.4) 4.6 (2.7) 0.370 5.9 (2.7) 5.2 (2.6) 0.428 9.7 (0.6) 3.7 (3.1) 0.109
EC
Social phobia 6.9 (3.3) 5.0 (4.0) 0.051 5.2 (2.9) 5.5 (2.5) 0.906 8.0 (1.0) 4.0 (4.6) 0.180
OCD 5.64 (3.3) 4.2 (3.1) 0.048 4.9 (2.4) 4.5 (2.5) 0.549 7.7 (1.5) 4.0 (3.6) 0.180
Panic/agoraphobia 4.0 (3.9) 3.3 (5.0) 0.474 6.3 (3.5) 4.2 (3.1) 0.036 10.3 (3.5) 3.7 (1.2) 0.109
R
Fear 4.4 (3.4) 4.1 (4.1) 0.959 2.9 (2.3) 2.2 (1.8) 0.075 5.7 (3.8) 3.0 (2.7) 0.109
Generalized anxiety 6.9 (2.8) 6.3 (3.1) 0.609 8.5 (2.9) 7.0 (2.2) 0.024 10.0 (2.0) 4.7 (3.8) 0.109
R
GADQ-IV 5.4 (2.2) 5.5 (2.8) 0.790 9.0 (1.2) 6.9 (2.2) 0.025 7.9 (2.3) 3.6 (3.3) 0.109
O
SASC-R total 34.2 (6.8) 30.0 (10.4) 0.093 31.3 (5.1) 31.4 (5.8) 0.759 32.7 (2.1) 22.7 (4.0) 0.102
SASC-R FNE 16.2 (3.1) 13.2 (4.6) 0.020 14.0 (3.1) 14.2 (2.4) 0.812 17.0 (1.7) 11.0 (2.0) 0.109
C
SASC-R SAD 11.9 (3.2) 11.1 (4.3) 0.421 12.0 (2.1) 11.9 (2.7) 0.964 9.3 (1.2) 7.0 (1.7) 0.109
SCAS-R SAD-G 6.2 (1.8) 5.8 (2.4) 0.438 5.6 (1.3) 5.2 (1.2) 0.471 6.3 (0.6) 4.7 (0.6) 0.102
N
SASI 13.8 (6.0) 10.8 (5.7) 0.181 17.0 (6.9) 11.8 (5.2) 0.018 26.0 (2.0) 14.0 (10.4) 0.285
U
n varies between variables due to missing data

CASI Childhood Anxiety Sensitivity Index for Children, SCAS Spence Children Anxiety Scale, OCD obsessive-compulsive disorder, GADQ-IV
Generalized Anxiety Disorder Questionnaire-IV, SASC-R Social Anxiety Scale for Children-Revised, FNE fear to negative evaluation, SAD social
anxiety distress, SAD-G social anxiety distress-generalized, SASI Separation Anxiety Symptom Inventory, FSSC-R Fear Survey Schedule for
Children-Revised
a
Related-samples Wilcoxon signed rank test; significance level is 0.05
561 somatic complaints, anxiety/depression, attention problems, the children agreed that once a week was enough compared 571
562 and aggressive behavior subscales (Table 4). Of note, with the 23.3% who thought it was not enough and would 572
563 results show a pattern where mothers tended to rate child have preferred more sessions a week. Moreover, a great 573
564 symptoms higher than fathers did. Moreover, parents did majority of the children (86.7%) thought that 1 h per session 574
565 not differ in their own anxiety levels (as measured by the was sufficient, while 10% would have preferred longer 575
566 STAI) and overall levels did not change after intervention. sessions, and just one participant (3.3%) reported that the 576
1 h-session was too long. Finally, regarding the total num- 577
567 Implementation Outcomes ber of sessions, 63.3% of the children reported that the 578
eight-session intervention was sufficient, while 36.7% 579
568 Acceptability would have preferred more sessions. Moreover, children 580
provided positive ratings of the content (M = 7.3; SD = 1.8) 581
569 Acceptability assessed participants’ feedback regarding the and their perceived usefulness of the group intervention 582
570 sessions. Regarding the frequency of the sessions, 76.7% of (M = 8.3; SD = 1.7); and perceived help from therapists 583
Table 4 Differences between measures reported by parents (n = 26)b

Mother Father
M SD M SD Range t p d
Child measures
CBCL totala 36.7 19.0 29.3 13.8 0–182 −2.06 0.056d 0.50
Thought problems a
1.5 1.2 1.3 1.2 0–14 −0.97 0.340 0.19
Attention problemsa 6.8 4.2 5.2 3.0 0–22 2.48 0.020 0.49
−0.47
F
Social problemsa 3.9 3.4 3.7 3.0 0–16 0.642 0.09
Internalizinga 16.2 8.6 12.8 6.1 0–64 −2. 4 0.058d 0.48
Withdrawn/depresseda
Somatic complaintsa
4.2 2.8 3.6 2.4
O 0–18 −1.29
−2.07
0.213 0.28
2.8 2.8 1.9 2.0
O 0–18 0.050 0.42
Anxious/depresseda 10.5 6.1 8.1 5.1 0–28 −2.83 0.010 0.58
PR
Anxiety scalea,c 11.9 5.9 9.5 4.2 0–32 −1.64 0.119 0.39
Externalizinga 11.1 7.8 8.0 6.5 0–66 −3.02 0.006 0.62
Rule-breaking behaviora 1.7 1.8 1.8 2.0 0–26 0.14 0.892 0.03
Aggressive behavior a
9.7 6.6 6.4 4.8 0–40 −4.08 0.000 0.82
D
Parent measures
TE
STAI-state (pre-int) 20.1 10.8 18.3 9.1 0–20 −0.90 0.380 0.20
STAI-trait (pre-int) 23.0 8.2 20.7 7.9 0–20 −1.09 0.289 0.23
STAI-state (post-int) 20.0 6.0 16.8 8.0 0–20 −1.77 0.102 0.49
EC
STAI-trait (post-int) 23.0 7.6 20.9 7.8 0–20 −0.93 0.369 0.26
Pre-intervention Post-intervention
R
M SD M SD Range t p d
R
Mother
STAI-state 20.5 11.2 20.2 10.0 0–20 0.22 0.826 0.05
O
STAI-trait 20.8 7.2 22.3 8.5 0–20 0.65 0.527 0.16

Father
C
STAI-state 18.4 10.5 17.5 8.5 0–20 0.59 0.566 0.15

N
STAI-trait 21.3 8.6 20.7 8.2 0–20 0.55 0.594 0.14

U
M mean, d Cohen’s d, t t-test, p p-value

a
Question categories were as follows: 0–2 where 0 = “not true,” 1 = “somewhat true”, and 2 = “often true”
b
Number of cases for each variable varies slightly due to missing data
c
Anxiety scale proposed by Kendall et al. (2007) by using 16 items from the CBCL (9, 11, 29, 30, 31, 32, 45, 46, 50, 56a, 56b, 56c, 56f, 71, 75,
112)
d
Trend observed for differences between maternal and paternal report
584 (M = 8.7; SD = 1.3), peers (M = 7.2; SD = 2.7) and parents decided to instead use social reward from parents and 635
585 (M = 7.2; SD = 2.6). Regarding the therapy, children therapists (i.e., positive reinforcement through descriptive 636
586 reported that the most useful component of the intervention and specific praise techniques regarding intentions to make 637
587 was “the challenges” (exposure component) (M = 8.2; SD a change, effort, and achievements). 638
588 = 2.3). Therapists were rated as being close, available and Only the full client workbook (16 sessions) is available 639
589 able to explain concepts clearly. Importantly, nine of ten in Spanish. Therefore, therapists had to choose only those 640
590 participating children would recommend the group to other activities related to the objectives proposed in the 8-session 641
591 child with similar difficulties, and 80% reported that the program. Therapists made a booklet with the selected 642
592 group was helpful, interesting, and enjoyable. sessions. 643
593 Parents also reported their levels of satisfaction with the Participants of the first group were given the booklet in 644
594 therapy. Results were consistent and stable among dyads, the first session. However, some of the participants forgot to 645
595 without significant differences between mother and father bring the resource in following sessions. For the remaining 646
596 report for any question. Overall satisfaction (M = 8.0; SD groups, we decided to only provide single pages needed for 647
597 = 1.3) was high. Satisfaction with specific components such each module in each session. 648
598 as the therapist availability and clarity (M = 7.9; SD = 1.8), In the first group, some written activities were assigned 649
599 interest in the content (M = 7.7; SD = 1.6), and helpfulness on top of the exposure tasks (i.e., write a negative thought 650
600 for their children (M = 6.8; SD = 1.6)) was good and you had this week, how did you feel after it, and how did 651
601 both mothers and fathers would recommend the group you behave after it). Participants from the first group 652
602 to other families. Finally, there was also an agreement reported feeling more anxious due to the responsibility of 653
603 between caregivers that other families’ advice was the writing about the content, as it seemed “like homework.” 654
604 least helpful component of parent sessions (M = 6.6; Instead, for the remaining groups, therapists did not assign 655
605 SD = 1.4). written activities at home and asked to be aware about the 656
content, as they would be asked in the following session. 657
F
606 Feasibility Home tasks were always exposure tasks. 658
O
Certain terms such as “negative thoughts” were not well 659
607 The intervention was considered feasible if most of the understood or did not engage participants as desired. We 660
O
608 participants completed six out of eight sessions. On aver- implemented the terminology that the children gave us, such 661
609 age, 7.1 (SD = 1.2) sessions were completed, with 88.8% of as “bomb thoughts.” They wrote their “bomb thoughts” in a 662
PR
610 attendance for children. Only two participants (6.1%) piece of paper on the floor and we represented the “bomb” 663
611 completely dropped out of the intervention. In general, at with a game. We used a ball to represent the thoughts, and 664
612 least one caregiver attended one of the parent sessions. we imagined that the ball was a “bomb about to explode” to 665
Participants arrived on time to sessions, and if there was any represent the negative thoughts. Therefore, the children
D
613 666
614 competing activity (i.e., school trip, medical appointment), threw the ball to the floor to make it “explode” when hitting 667
TE
615 parents let therapists know in advance. the floor at the same time that they said the negative 668
616 Moreover, the intervention was considered feasible after thoughts aloud. 669
617 assessing clinical service feedback. All sessions were con- Finally, all the activities were adapted to the group for- 670
EC
618 ducted as planned and covered the pre-established content. mat in order to maximize participation. For instance, in 671
619 Nevertheless, important considerations need to be pointed order to talk about specific somatic reactions to anxiety 672
620 out relating to barriers encountered in the implementation of (session 2), a human-size body shape was made of paper 673
R
621 the first group. After considering the clinical feedback for and hung onto the wall. Each participant had cards they 674
622 the first group, the following adaptations were made to the could draw or write the body parts where they experienced 675
R
623 original program for the rest of the groups: somatic symptoms of anxiety (i.e., head, heart, sweaty 676
Choosing a fun activity for the end of the session, at the hands, etc.). Then they were invited to stick the cards on the
O
624 677
625 beginning of each session, was overly time-consuming and corresponding body part of the body shape on the wall. This 678
C
626 considered unfeasible. Instead we decided to create a list of activity showed different forms anxiety could be expressed, 679
627 eight fun activities (on the very first day), chosen by each but also served to demonstrate commonalties with other 680
N
628 member of the group. This served as a cohesive warm-up group members. 681
and gave structure for the rest of the sessions. Of note, one of the groups was undertaken in summer
U
629 682
630 Using stickers as a reward was considered not useful (school holidays). This was the only group with two parti- 683
631 with our population due to their older age, but also due to cipants dropping out, and had more inconsistent attendance 684
632 differences in the Spanish educational system compared to compared to the rest of groups. This group participants’ 685
633 the American system, where stickers are frequently used. characteristics differed from the other groups (i.e., lower 686
634 Stickers were not viewed as a salient reward, and we SES cohort and less structure without school schedule). 687
688 Finally, all participants (100%) reported that they felt et al. 2010) and our results also highlight symptom 738
689 safe during the intervention (i.e., scores higher than 8 out of comorbidity. 739
690 10 for “Did you feel safe to share your difficulties in the Regarding other implementation outcomes, self-report 740
691 group?” and “If something bad had happened during a measures of the satisfaction with the group from both par- 741
692 session, did you feel that the therapist would have helped ticipants and their caregivers were comparable, and 742
693 you?”). Despite the fact that the exposure sessions were recruitment was better and the attrition was lower than the 743
694 difficult (i.e., share a story in front of an unfamiliar audi- original 16-session CBT (Kendall and Sugarman 1997; 744
695 ence, surprise exam), participants reported trusting thera- Kendall et al. 1997). Therapists reported that the groups 745
696 pists and feeling safe. could be implemented, although some changes were needed 746
to adapt to the Spanish public mental health system (i.e., 747
adapting all the activities to a group format; less time in 748
697 Discussion choosing a fun activity; not completely relying on the 749
manual; changes in some terminology; and avoiding 750
698 This study was designed as an effectiveness-implementation undertaking groups during school breaks). 751
699 hybrid study (Curran et al. 2012). The objective of this Regarding effectiveness outcomes, there was a sig- 752
700 study was to test effectiveness and gather information on nificant reduction in all anxiety scales with effect sizes 753
701 the delivery of a group adaptation of the individual Brief ranging from d = 0.42 for social anxiety to d = 0.67 for 754
702 Coping Cat (Beidas et al. 2013; Crawley et al. 2013). The separation anxiety. Consistent with preliminary results on 755
703 target population was children and young adolescents with individual therapy, our findings showed that group BCBT 756
704 anxiety disorders in the Spanish public mental health sys- was effective to reduce anxiety without the progressive 757
705 tem after intervention participation. Our results showed both muscle relaxation component usually included in CBT for 758
706 intervention effectiveness and implementation effectiveness child and adolescent interventions for anxiety (Jennifer L. 759
707 (Proctor et al. 2011). Our findings indicated that the inter- Hudson 2005; Rapee 2000). Providing condensed psy- 760
F
708 vention was (i) potentially clinically beneficial as there was choeducation and focusing on exposure may be the most 761
O
709 an overall decrease of anxiety levels in all the scales mea- relevant mechanisms of change (Crawley et al. 2013). 762
710 sured; (ii) acceptable, with a 89% attendance at sessions and Furthermore, our results from the overall group are con- 763
O
711 positive ratings provided by both child participants and their sistent with preliminary results from a single case study 764
712 families as to their perceived usefulness and helpfulness of within our sample, which also reported positive results to 765
PR
713 the intervention; (iii) feasible, although some adaptations decrease specific phobia (Santesteban-Echarri et al. 2016). 766
714 for the Spanish population and service constraints needed to It seems that BCBT may also reduce comorbid anxiety 767
715 be implemented; and (iv) safe, since all participants reported disorders (Ollendick et al. 2010) and phobias (Öst et al. 768
feeling safe and trusting therapists. The present findings 2001).
D
716 769
717 provide support for group BCBT for anxiety reduction When effectiveness outcomes were stratified by diag- 770
TE
718 within clinical samples in a community setting in the nosis, those in the SP group seemed to have a reduction in 771
719 Spanish public mental health system. OCD and fear to negative evaluation symptoms specifically, 772
720 Prevalence rates of our sample, mainly participants in while those in the GAD group had a reduction in general- 773
EC
721 their early adolescence, were comparable to those reported ized anxiety, panic/agoraphobia, and separation anxiety 774
722 in literature, with GAD and SP being the most prevalent symptoms in particular. Exposure, even without cognitive 775
723 disorder among adolescents (Burstein et al. 2011) and SAD therapy seems to be effective to decrease SP symptoms 776
R
724 being the least prevalent, as it is usually more prevalent (Feske and Chambless 1995). Group therapy is in itself an 777
725 among younger children (Kessler et al. 2012). As expected, exposure to social situations, which can provide contra- 778
R
726 there were differences in symptoms by baseline diagnosis dictory evidence to negative thoughts and distortions related 779
(SP, GAD and SAD), highlighting that the clinical diag- to social expectations (Kaczkurkin and Foa 2015). This is
O
727 780
728 nosis made by therapists adequately categorized each child probably why those in the SP group benefited from the 781
C
729 under their most prevalent disorder. One of the criticisms group, reducing their fear of negative evaluation. Moreover, 782
730 that pure research studies receive from practicing clinicians seeing that there were more children with the same diffi- 783
N
731 is the need of “real clinical practice” diagnostic strategies culties and the effort therapists made to normalize anxiety 784
(i.e., not using a structured interview to diagnose partici- and “failure” may have contributed to the reduction of the
U
732 785
733 pants, as it is time- and resource-consuming). Our results perfectionism traits of participants in the SP group. Our 786
734 provide an indicator that well-trained clinicians can suc- results for the GAD group are promising. First, GAD is the 787
735 cessfully classify participants in a diagnostic category. most prevalent anxiety disorder during adolescence (Mer- 788
736 However, as referred to in the literature, a high comorbidity ikangas et al. 2010); second, due to its chronic course, GAD 789
737 between different anxiety disorders is expected (Merikangas is one of the anxiety disorders causing greater suffering; 790
791 finally GAD is one of the most treatment-resistant disorders our program or more time to properly respond to treatment. 844
792 (Brown et al. 1994). For instance, Olivares et al. (2002) conducted an RCT 845
793 Sensitivity analyses excluding participants from the first consisting of a group therapy with the Social Effectiveness 846
794 group were performed to take into account the protocol Therapy for Adolescents-Spanish version (Olivares and 847
795 changes after experiencing some implementation chal- García-López 2001), and reported a significant reduction of 848
796 lenges. Although the pattern of results was very similar, the SP compared with the control group. Although main com- 849
797 reduction of symptoms for the SCAS-Fear subscale and the ponents of the intervention were similar to the Brief Coping 850
798 SAD-G subscale of the SASC-R became significant. This Cat (i.e., psychoeducation, exposure, and programmed 851
799 finding could be spurious, or it may indicate that the pro- practice), they included a social skills training module and 852
800 tocol changes worked better for the Spanish population the intervention was a high-intensity program (29 sessions 853
801 receiving help in the public mental health system than the over 17 weeks, twice a week). 854
802 original protocol (designed for the American context). One In the present study, eight sessions were sufficient to 855
803 of the major changes implemented was to avoid written promote changes and significantly reduce anxiety symp- 856
804 homework tasks. Although the Coping Cat uses the “Show toms in children from a moderate to low SES, and the 857
805 That I Can” term to avoid the term “homework” when intervention appeared to provide useful tools for partici- 858
806 referring to take-home tasks, this approach may still elicit pants to use in stressful situations. Therefore, group BCBT 859
807 anxiety for children related to perfectionism, or negative for children and adolescents with anxiety could be an 860
808 evaluation concerns (Hudson and Kendall 2002). One of the effective and cost-efficient intervention in day-to-day clin- 861
809 most complicated aspects of therapy, especially with chil- ical care in the Spanish public mental health system. 862
810 dren, is compliance. The original therapy structure is clear Although high rates of child and adolescent anxiety dis- 863
811 about compliance. Therapists should review the quality of orders are reported in Spain and CBT is the recommended 864
812 and whether written homework was done. When non- treatment, most children and adolescents do not receive 865
813 compliance occurs, rewards are not given. Because home- treatment due to the congested system (Cátedra de Psi- 866
F
814 work compliance may be an indicator of better outcome quiatría Infantil Fundación Alicia Koplowitz 2014; Tizón 867
O
815 (Crawford et al. 2017), in the adaptation we made, we still García 2002). Therefore, changing the individual BCBT 868
816 covered the “Show That I Can” tasks, but we did not ask format to a group format may be a valuable resource for 869
O
817 participants to write them down. Instead, we completed the both usual clinical care and school settings to avoid the long 870
818 task in the session aloud with each of the participants, wait-lists of the public mental health system (Mychailyszyn 871
PR
819 serving as a model for the rest of the group. The rationale et al. 2012). 872
820 for this change was the reliance of the Spanish education
821 system on substantial homework assignments from Grade 1
onwards compared with other countries (i.e., USA). Since Limitations
D
822 873
823 formal education starts at three years of age, by the age of
TE
824 seven, homework assignments from each subject are given Reduction of anxiety symptoms in all the overall measures 874
825 daily and may have a negative connotation among students. provides promising results for progression to a large-scale 875
826 It could be the case that separating the “at-school tasks” RCT testing implementation of a group BCBT for anxiety 876
EC
827 from the “at-group tasks” was a good strategy to avoid an in the Spanish public mental health system. Nevertheless, 877
828 anxiety response, which usually leads to behaviors of some limitations apply to the preset study. Some of the 878
829 avoidance, forgetting homework, or desire to please the disadvantages of group settings are the need of a number of 879
R
830 therapist. Both fears and social anxiety-generalized symp- referrals before the group can start. Diagnoses of the par- 880
831 toms were significantly reduced after the protocol changes. ticipants were based on referral notes, and diagnoses were 881
R
832 This finding may mean that children with anxiety perceived not confirmed through a structured diagnostic interview. 882
the group, contrary to the school setting, as a safe envir- The lack of confirmation of diagnoses could lead to varia-
O
833 883
834 onment, which did not add extra pressure to perform bility of child characteristics due to referring providers. 884
C
835 (Mychailyszyn et al. 2010; Nail et al. 2015). Moreover, due to the community mental health context of 885
836 However, similar to results derived from the individual this study, all participants had previously seen an individual 886
N
837 Brief Coping Cat (Crawley et al. 2013), there was not a therapist at least once. We had no information of the 887
significant improvement in SP within the group setting. This duration of previous treatment and the progress in the
U
838 888
839 result is consistent with previous studies, and it suggests reduction of symptoms. Future research should adjust for 889
840 that CBT gains for children and adolescents with SP are not the length of treatment or the number of previous psycho- 890
841 as pronounced as for other anxiety disorders (Crawley et al. logical sessions. Further, the sample size was small and we 891
842 2008; Ginsburg et al. 2011). It may be the case that this did not have a comparison control condition. Therefore, it is 892
843 cohort needs further training in other skills not included in possible that changes evidenced could be associated with 893
894 repeated assessment or child maturation, and true clinical Acknowledgements The authors acknowledge all the clinicians 946
895 benefits remain unknown until an RCT can be undertaken. involved in providing the intervention as co-therapists: David Rentero- 947
Martin, Patricia Nava-García, Sergio Benavente-López, Esther Martín- 948
896 We could not ascertain maintenance of treatment effects
Ávila and Manuel Nieves-Carnicer and the rest of child and adolescent 949
897 over a period of time because we had no follow-up measure clinicians from the Mental Health Centers from Villaverde and Car- 950
898 beside the post-treatment assessment. Future studies should abanchel for assisting with participant recruitment. Finally, the authors 951
899 undertake follow-up assessments at 3 and 6 months. would like to thank all the participating children and their families for 952
their involvement with the intervention. 953
900 Although we performed assessments by independent clin-
901 icians, due to the single-group assessment, blinding was not Funding O.S.-E., the first author, was supported by a Research Fel- 954
902 possible. Moreover, careful consideration should be given lowship from the Alicia Koplowitz Foundation (Spain) and an 955
903 to generalizing these results because our sample is not Endeavour Research Fellowship (Australia). S.M.R. was supported via 956
the Mary Elizabeth Watson Early Career Fellowship in Allied Health, 957
904 necessarily representative of other child and adolescent provided by Melbourne Health. 958
905 outpatient units from Madrid (i.e., Villaverde and Car-
906 abanchel belong to a lower-income area of the state). Future Author Contributions O.S.-E.: designed and executed the study, ana- 959
907 groups should take place during school year, avoiding lyzed the data, and wrote the paper. L.H.-A.: collaborated with the 960
design and execution of the study as a co-therapist of the groups. S.M. 961
908 summer months in order to maximize engagement. Finally, R.: assisted with the analyses and editing of the study. M.J.G.-L., M. 962
909 more parent report questionnaires regarding children’s S.-V., and J.C.E.-J.: collaborated with the design and writing of the 963
910 symptoms should be assessed both at pre- and post- study. M.A.J.-A.: collaborated in the editing of the final manuscript. 964
911 treatment as parent’s and children’s reports do not neces-
912 sarily correlate. Specifically, mother report could be more Compliance with Ethical Standards 965
913 accurate than the child report. Furthermore, parents may
Conflict of Interest The authors declare that they have no conflict of 966
914 feel more integrated and supported by the addition of more interest. 967
915 parental sessions with a more structured framework within
916 the intervention.
F
917 To sum up, the group CBCT pilot study using the Brief References 968
O
918 Coping Cat demonstrated the intervention to be engaging,
919 feasible, and safe for children and young adolescents with Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4- 969
O
920 anxiety disorders. Both parents and children reported 18 and 1991 profile. Department of Psychiatry, University of 970
921 positive feedback regarding the intervention and facilitating Vermont. 971 Q4
PR
Albores-gallo, L., Lara-Muñoz, C., Esperón-Vargas, C., Cárdenas, J. 972

922 therapists. High retention rates suggest the overall accept- A., Pérez, A. M., & Villanueva, G. (2007). Validity and reability 973
923 ability of the intervention. The pre-post decrease of anxiety of the CBCL/6-18. Includes DSH scales. Actas Españolas 974
924 symptoms across all of the scales provides promising data Deĺ előtt Psiquiatría, 35, 393–399. 975
for conducting a controlled trial and implementing group American Psychiatric Association. (2000). Diagnostic and Statistical 976
D
925
Manual of Mental Disorders (4th ed. - Text Revision) (DSM-IV- 977
926 BCBT within standard clinical practice in Spain. Due to the TR). Washington, DC. 978 Q5
TE
927 high prevalence of anxiety disorders among child and Barlow, D. H. (2002). Anxiety and its disorders: the nature and 979
928 adolescent populations and low clinical resources available treatment of anxiety and panic (2nd edition). New York: Guilford 980
929 in Spain, a group BCBT intervention could be a cost- Press. 981
EC
Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Höfler, M., Lieb, R., 982
930 effective means reaching more children with difficulties by & Wittchen, H.-U. (2007). Incidence of social anxiety disorder 983
931 reducing waiting lists and time lapsed between visits. and the consistent risk for secondary depression in the first three 984
932 Nevertheless, future research should focus on determining decades of life. Archives of General Psychiatry, 64(8), 903–912. 985
R
933 mechanisms of action for the reduction of SP symptoms and Beidas, R. D. S., Mychailyszyn, M. P., Podell, J. L., & Kendall, P. C. 986
(2013). Brief cognitive-behavioral therapy for anxious youth: the 987
934 include therapeutic tools (i.e., social skills training) specific
R
inner workings. Cognitive and Behavioral Practice, 20(2), 988

935 for social phobia as a component of the BCBT. Finally, our 997–1003. 989
results underscore the need for a larger-scale hybrid
O
936 Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence- 990
937 effectiveness-implementation trial of the BCBT in a group based practice: a critical review of studies from a systems- 991
contexual perspective. Clinical Psychology: Science and Prac- 992
C
938 setting throughout more community mental health centers in tice, 17(1), 1–30. 993
939 different Spanish states, so that patients can access and Beidas, R. S., Mychailyszyn, M. P., Edmunds, J. M., Khanna, M., 994
N
940 benefit from an evidence-based treatment in community Downey, M. M., & Kendall, P. C. (2012). Training school mental 995
settings. Such effort may translate into translational health providers to deliver cognitive-behavioral therapy. School 996
U
941
Mental Health, 4(4), 197–206. 997
942 improvement in clinical treatment uptake, including strate- Bittner, A., Egger, H. L., Erkanli, A., Jane Costello, E., Foley, D. L., & 998
943 gies being implemented more effectively, and an important Angold, A. (2007). What do childhood anxiety disorders predict?. 999
Q3 944 source of information for public mental health decision Journal of Child Psychology and Psychiatry, 48(12), 1174–1183. 1000
945 makers. Boden, J. M., Fergusson, D. M., & Horwood, L. J. (2007). Anxiety 1001
disorders and suicidal behaviours in adolescence and young 1002
1003 adulthood: findings from a longitudinal study. Psychological Fernández Aláez, M., Martínez-Arias, R., & Rodríguez-Sutil, C. 1068
1004 Medicine, 37, 431–440. (2000). Prevalencia de trastornos psicológicos en niños y ado- 1069
1005 Brown, T. A., Barlow, D. H., & Liebowitz, M. R. (1994). The lescentes, su relación con la edad y el género. Psicothema, 12, 1070
1006 empirical basis of generalized anxiety disorder. American Journal 525–532. 1071
1007 of Psychiatry, 151, 1272–1280. Feske, U., & Chambless, D. L. (1995). Cognitive behavioral versus 1072
1008 Buela-Casal, G., Guillén-Riquelme, A., & Seisdedos-Cubero, N. exposure only treatment for social phobia: a meta-analysis. 1073
1009 (2011). Cuestionario de Ansiedad Estado-Rasgo: Adaptación Behavior Therapy, 26, 695–720. 1074
1010 espanõ la. 8a ed. Madrid: TEA. Flannery-Schroeder, E. C., & Kendall, P. C. (2000). Group and indi- 1075
1011 Burstein, M., Jian-Ping, H., Kattan, G., Albano, A. M., Avenevoli, S., vidual cognitive-behavioral treatments for youth with anxiety 1076
1012 & Merikangas, K. (2011). Social phobia and subtypes in the disorders: A randomized clinical trial. Cognitive Therapy and 1077
1013 National Comorbidity Survey-adolescent supplement: prevalence, Research, 24(3), 251–278. 1078
1014 correlates, and comorbidity. Journal of the American Academy Flannery-Schroeder, E., Choudhury, M. S., & Kendall, P. C. (2005). 1079
1015 Children Adolescent Psychiatry, 50(9), 870–880. Group and individual cognitive-behavioral treatments for youth 1080
1016 Cartwright-Hatton, S., Roberts, C., Chitsabesan, P., Fothergill, C., & with anxiety disorders: 1-year follow-up. Cognitive Therapy and 1081
1017 Harrington, R. (2004). Systematic review of the efficacy of Research, 29(2), 253–259. 1082
1018 cognitive behaviour therapies for childhood and adolescent Ginsburg, G. S., Sakolsky, D., Piacentini, J., Walkup, J. T., Coffey, K. 1083
1019 anxiety disorders. The British Journal of Clinical Psychology, 43, A., Keeton, C. P., & McCracken, J. T. (2011). Remission after 1084
1020 421–436. acute treatment in children and adolescents with anxiety dis- 1085
1021 Cátedra de Psiquiatría Infantil Fundación Alicia Koplowitz. (2014). orders: findings from the CAMS. Journal of Consulting and 1086
1022 Libro blanco de la psiquiatría del niño y el adolescente. In C. Clinical Psychology, 79(6), 806–813. 1087
Q6 1023 Arango (Ed.). Madrid: Fundación Alicia Koplowitz. Godoy, A., Gavino, A., Carrillo, F., Cobos, M. P., & Quintero, C. 1088
1024 Costello, E. J., He, J., Sampson, N. A., Kessler, R. C., & Merikangas, (2011). Composición factorial de la versión española de la 1089
1025 K. R. (2014). Services for adolescents with psychiatric disorders: Spence Children Anxiety Scale (SCAS). Psicothema, 23(2), 1090
1026 12-month data from the National Comorbidity Survey- 289–294. 1091
1027 Adolescent. Psychiatric Services, 65(3), 359–366. Gregory, A. M., Caspi, A., Moffitt, T. E., Koenen, K., Eley, T. C., & 1092
1028 Crawford, E. A., Frank, H. E., Palitz, S. A., Davis, J. P., & Kendall, P. Poulton, R. (2007). Juvenile mental health histories of adults with 1093
1029 C. (2017). Process factors associated with improved outcomes in anxiety disorders. The American Journal of Psychiatry, 164, 1094
Q7 1030 CBT for anxious youth: therapeutic content, alliance, and thera- 301–308. 1095
F
1031 pist actions. Cognitive Therapy and Research, 1–12. Hudson, J. L. (2005). Mechanisms of change in cognitive behavioral 1096
1032 Crawley, S. A., Beidas, R. S., Benjamin, C. L., Martin, E., & Kendall, therapy for anxious youth. Clinical Psychology: Science and 1097
O
1033 P. C. (2008). Treating socially phobic youth with CBT: differ- Practice, 12(2), 161–165. 1098
1034 ential outcomes and treatment considerations. Behavioural and Hudson, J. L., & Kendall, P. C. (2002). Showing you can do it: 1099
1035 Cognitive Psychotherapy, 36(4), 379–389.
O
homework in therapy for children and adolescents with anxiety 1100
1036 Crawley, S. A., Kendall, P. C., Courtney, L. B., Chiaying, W., Beidas, disorders. Psychotherapy in Practice. https://doi.org/10.1002/ 1101
PR
1037 R. S., Podell, J. L., & Mauro, C. (2013). Brief cognitive- jclp.10030. 1102
1038 behavioral therapy for anxious youth: feasibility and initial out- In-Albon, T., & Schneider, S. (2006). Psychotherapy of childhood 1103
1039 comes. Cognitive and Behavioral Practice, 20(2), 997–1003. anxiety disorders: a meta-analysis. Psychotherapy and Psycho- 1104
1040 Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. somatics, 76(1), 15–24. 1105
1041 (2012). Effectiveness-implementation hybrid designs: combining Insituto Nacional de Estadistica. (2014). Decil de salarios del empleo 1106 Q8
D
1042 elements of clinical effectiveness and implementation research to principal. Encuesta de Población activa (EPA). Año 2014., 1–22. 1107
1043 enhance public health impact. Medical Care. https://doi.org/10. http://www.ine.es/prensa/np939.pdf. 1108
TE
1044 1097/MLR.0b013e3182408812. Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy 1109
1045 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, for anxiety disorders: an update on the empirical evidence. Ser- 1110
1046 J. A., & Lowery, J. C. (2009). Fostering implementation of health vier Research Group Dialogues Clinical Neuroscience. https:// 1111
1047 services research findings into practice: a consolidated framework doi.org/10.4088/JCP.12r07757. 1112
EC
1048 for advancing implementation science. Implementation Science, Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., 1113
1049 4(50), 40–55. Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy 1114
1050 de Souza, M. A. M., Salum, G. A., Jarros, R. B., Isolan, L., Davis, R., for youths with anxiety disorders: a second randomized clinical 1115
1051 Knijnik, D., & Heldt, E. (2013). Cognitive-behavioral group trial. Journal of Consulting and Clinical Psychology, 65(3), 1116
R
1052 therapy for youths with anxiety disorders in the community: 366–380. 1117
1053 effectiveness in low and middle income countries. Behavioural Kendall, P. C., Hudson, J. L., Gosch, E., Flannery-schroeder, E., & 1118
R
1054 and Cognitive Psychotherapy, 41(3), 255–264. Suveg, C. (2008). Cognitive–behavioral therapy for anxiety dis- 1119
1055 Drake, K. L., & Ginsburg, G. S. (2012). Family factors in the devel- ordered youth: A randomized clinical trial evaluating child and 1120
O
1056 opment, treatment, and prevention of childhood anxiety disorders. family modalities. Journal of Consulting and Clinical Psychol- 1121
1057 Clinical Child and Family Psychology Review, 15(2), 144–162. ogy, 76(2), 282–297. 1122
C
1058 Ebesutani, C., Bernstein, A., Nakamura, B. J., Chorpita, B. F., Higa- Kendall, P. C., & Kosovsky, R. P., (2010a). El gato valiente. Buenos 1123
1059 Mcmillan, C. K., & Weisz, J. R. (2010). Concurrent validity of Aires: Akadia. 1124
N
1060 the child behavior checklist DSM-oriented scales: correspon- Kendall, P. C., & Kosovsky, R. P., (2010b). Tratamiento cognitivo- 1125
1061 dence with DSM diagnoses and comparison to syndrome scales. conductual para trastornos de ansiedad en niños. Manual para el 1126
U
1062 Journal of Psychopathology and Behavioral Assessment, https:// terapeuta. Buenos Aires: Akadia. 1127
1063 doi.org/10.1007/s10862-009-9174-9. Kendall, P. C., Puliafico, A. C., Barmish, A. J., Choudhury, M. S., 1128
1064 Ezpeleta, L., Guillamon, N., Granero, R., de la Osa, N., Domenech, J. Henin, A., & Treadwell, K. S. (2007). Assessing anxiety with the 1129
1065 M., & Moya, I. (2007). Prevalence of mental disorders in children Child Behavior Checklist and the Teacher Report Form. Journal 1130
1066 and adolescents from a Spanish slum. Social Science and Medi- of Anxiety Disorders. https://doi.org/10.1016/j.janxdis.2006.10. 1131
1067 cine, 64(4), 842–849. 012. 1132
1133 Kendall, P. C., & Sugarman, A. (1997). Attrition in the treatment of Preliminary reliability and validity of the Generalized Anxiety 1199
1134 childhood anxiety disorders. Journal of Consulting and Clinical Disorder Questionnaire-IV: a revised self-report diagnostic mea- 1200
1135 Psychology, 65(5), 883–888. sure of generalized anxiety disorder. Behavior Therapy, 33, 1201
1136 Kendall, P. C., & Zupan, B. A. (1981). Individual versus group 215–233. 1202
1137 application of cognitive-behavioral self-control procedures with Olivares, J., García-López, L.-J., Beidel, D. C., Turner, S. M., Albano, 1203
1138 children. Behavior Therapy, 12(3), 344–359. A. M., & Hidalgo, M.-D. (2002). Results at long-term among 1204
1139 Kendall, P., & Hedtke, K. (2006). Cognitive-behavioral therapy for three psychological treatments for adolescents with generalized 1205
1140 anxious youth: therapist manual. Ardmore: Workbook Publish- social phobia (I): Statistical significance. Psicología Conductual, 1206
1141 ing 3. 10(I), 147–164. 1207
1142 Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Olivares, J., & García-López, L. J. (2001). Un nuevo tratamiento 1208
1143 Walters, E. E. (2005). Lifetime prevalence and age-of-onset dis- multicomponente para adolescentes con fobia social generalizada: 1209
1144 tributions of DSM-IV disorders in the National Comorbidity resultados de un estudio piloto. Psicología Conductual, 9, 1210
1145 Survey Replication. Archives of General Psychiatry, 62, 247–254. 1211
1146 593–602. Ollendick, T. H., Öst, L. G., Reuterskiöld, L., & Costa, N. (2010). 1212
1147 Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Comorbidity in youth with specific phobias: impact of comor- 1213
1148 Wittchen, H. U. (2012). Twelve-month and lifetime prevalence bidity on treatment outcome and the impact of treatment on 1214
1149 and lifetime morbid risk of anxiety and mood disorders in the comorbid disorders. Behaviour Research and Therapy, 48(9), 1215
1150 United States. International Journal of Methods in Psychiatric 827–831. 1216
1151 Research, 21(3), 169–184. Öst, L. G., Svensson, L., Hellström, K., & Lindwall, R. (2001). One- 1217
1152 La Greca, A. M., & Stone, W. L. (1993). Social Anxiety Scale for session treatment of specific phobias in youths: a randomized 1218
1153 Children-Revised: factor structure and concurrent validity. Jour- clinical trial. Journal of Consulting and Clinical Psychology, 69 1219
1154 nal of Clinical Child Psychology, 22, 17–27. (5), 814–824. 1220
1155 Liber, J. M., Van Widenfelt, B. M., Utens, E. M. W. J., Ferdinand, R. Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The 1221
1156 F., Van Der Leeden, A. J. M., Gastel, W., Van, & Treffers, P. D. risk for early-adulthood anxiety and depressive disorders in 1222
1157 A. (2008). No differences between group versus individual adolescents with anxiety and depressive disorders. Archives of 1223
1158 treatment of childhood anxiety disorders in a randomised clinical General Psychiatry, 55(1), 56–64. 1224
1159 trial. Journal of Child Psychology and Psychiatry, 49(8), Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., 1225
1160 886–893. Bunger, A., & Hensley, M. (2011). Outcomes for implementation 1226
F
1161 Manassis, K., Mendlowitz, S. L., Scapillato, D., Avery, D., Fiksen- research: Conceptual distinctions, measurement challenges, and 1227
1162 baum, L., Freire, M., & Owens, M. (2002). Group and individual research agenda. Administrative Policy in Mental Health, 38, 1228
O
1163 cognitive-behavioral therapy for childhood anxiety disorders: a 65–76. 1229
1164 randomized trial. Journal of the American Academy of Child and Rapee, R. M. (2000). Group treatment of children with anxiety dis- 1230
1165 Adolescent Psychiatry, 41, 1423–1430.
O
orders: outcome and predictors of treatment response. Australian 1231
1166 Merikangas, K., Jian-ping, H., Burstein, M., Swanson, S., Avenevoli, Journal of Psychology, 52(3), 125–130. 1232
PR
1167 S., Lihong, C., & Swendsen, J. (2010). Lifetime prevalence of Rapee, R. M. (2012). Family factors in the development and man- 1233
1168 mental disorders in US adolescents: results from the National agement of anxiety disorders. Clinical Child and Family Psy- 1234
1169 Comorbidity Study-Adolescent supplement. Journal of the chology Review, 15(1), 69–80. 1235
1170 American Academy Children Adolescent Psychiatry, 49(10), Remschmidt, H., & Engeland, H. (1999). Child and adolescent psy- 1236
1171 980–989. chiatry in Europe. Historical development, current situation, 1237
D
1172 Muris, P., Schmidt, H., Lambrichs, R., & Meesters, C. (2001). Pro- future perspectives. In H. Remschmidt, & H. Engeland (Eds.), 1238
1173 tective and vulnerability factors of depression in normal adoles- New York: Springer Steinkopff. 1239 Q9
TE
1174 cents. Behaviour Research and Therapy, 39(5), 555–565. Sandín, B. (1997). Ansiedad, miedos y fobias en niños y adolescentes. 1240
1175 Muroff, J., Ross, A., (2011). Social disability and impairment in Madrid: Dykinson-Psicología. 1241
1176 childhood anxiety. In D. M. Storch, & E. A. Storch (Eds.), Santesteban-Echarri, O., Hernández-Arroyo, L., Rentero-Martín, D., & 1242
1177 Handbook of child and adolescent anxiety disorders (pp. Güerre-Lobera, M. J. (2015). Programa de terapia grupal para 1243
EC
1178 457–478). New York: Springer Science Business Media. niños con ansiedad. Cuadernos Deĺ előtt Salud Mental Del, 12 1244
1179 Mychailyszyn, M. P., Brodman, D. M., Read, K. L., & Kendall, P. C. (11), 134. 1245
1180 (2012). Cognitive-behavioral school-based interventions for Santesteban-Echarri, O., Martín, D. R., Güerre Lobera, M. J., Espín 1246
1181 anxious and depressed youth: a meta-analysis of outcomes. Jaime, J. C., & Jiménez-Arriero, M. Á. (2016). Cognitive- 1247
R
1182 Clinical Psychology: Science and Practice, 19(2), 129–153. behavioral treatment of specific phobia in childhood: a case 1248
1183 Mychailyszyn, M. P., Mendez, J. L., & Kendall, P. C. (2010). School study. Ansiedad Y Estres, 22(2–3). 1249 Q10
R
1184 functioning in youth with and without anxiety disorders: com- Santesteban-Echarri, O., Rice, S., Wadley, G., Lederman, R., D’Al- 1250
1185 parisons by diagnosis and comorbidity. School Psychology fonso, S., Russon, P., & Álvarez-Jiménez, M. (2017). A next- 1251
O
1186 Review, 39(1), 106–121. generation social media-based relapse prevention intervention for 1252
1187 Nail, J. E., Christofferson, J., Ginsburg, G. S., Drake, K., Kendall, P. youth depression: qualitative data on user experience outcomes 1253
C
1188 C., McCracken, J. T., & Sakolsky, D. (2015). Academic for social networking, safety, and clinical benefit. Internet 1254
1189 impairment and impact of treatments among youth with anxiety Interventions, 9(1), 65–73. 1255
N
1190 disorders. Child and Youth Care Forum, 44(3), 327–342. Settipani, C. A., & Kendall, P. C. (2013). Social functioning in youth 1256
1191 Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., with anxiety disorders: association with anxiety severity and 1257
U
1192 Przeworski, A., Erickson, T., & Cashman-McGrath, L. (2002). outcomes from cognitive-behavioral therapy. Child Psychiatry 1258
1193 Preliminary reliability and validity of the generalized anxiety and Human Development, 44(1), 1–18. 1259
1194 disorder questionnaire-IV: a revised self-report diagnostic mea- Silove, D., Manicavasagar, V., O’Connell, D., Blaszczynski, A., 1260
1195 sure of generalized anxiety disorder. Behavior Therapy, 33(2), Wagner, R., & Henry, J. (1993). The development of the 1261
1196 215–233. Separation Anxiety Symptom Inventory (SASI). The Australian 1262
1197 Newman, M. G., Zuelling, A. R., Kachin, K. E., Constantino, M. J., and New Zealand Journal of Psychiatry, 27(3), 477–488. 1263
1198 Przeworski, A., Erickson, T., & Cashman-McGrath, L. (2002).
1264 Spence, S. H. (1997). Structure of anxiety symptoms among children: Primaria. Revista Pedriatría Deĺ előtt Atención Primaria, 4(13), 1277
1265 a confirmatory factor-analytic study. Journal of Abnormal Psy- 81–106. 1278
1266 chology, 106, 280–297. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, 1279
1267 Spielberg, C. (1973). Manual for the state-trait anxiety inventory for S. N., Sherrill, J. T., & Kendall, P. C. (2008). Cognitive beha- 1280
1268 children. Palo Alto: Consulting Psychology Press. vioral therapy, sertraline, or a combination in childhood anxiety. 1281
1269 Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inven- The New England Journal of Medicine, 359(26), 2753–2766. 1282
1270 tory STAI. Palo Alto: Mind Garden. Weissman, M. M., Wolk, S., Wickramaratne, P., Goldstein, R. B., 1283
1271 Storch, E. A., Eisenberg, P. S., Roberti, J. W., & Barlas, M. E. (2003). Adams, P., Greenwald, S., & Steinberg, D. (1999). Children with 1284
1272 Reliability and validity of the Social Anxiety Scale for Children prepubertal-onset major depressive disorder and anxiety grown 1285
1273 — revised for Hispanic children. Hispanic Journal of Behavioral up. Archives of General Psychiatry, 56(9), 794–801. 1286
1274 Sciences, 25(3), 410–422. World Health Organization. (1992). The ICD-10 classification of 1287
1275 Tizón García, J. (2002). Prevención e intervención en la salud mental mental and behavioural disorders: clinical descriptions and 1288
1276 de la primera infancia desde los dispositivos de Atención diagnostic guidelines. Geneva: World Health Organization. 1289
F
O
O
PR
D
TE
EC
R
R
O
C
N
U
View publication stats

Santesteban-Echarrietal. 2018 BriefCopingCat Acceptedversion

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Santesteban-Echarrietal. 2018 BriefCopingCat Acceptedversion

Transféré par

Droits d'auteur :

Formats disponibles

See discussions, stats, and author proﬁles for this publication at: https://www.researchgate.

Article in Journal of Child and Family Studies · June 2018

Olga Santesteban-Echarri Simon M Rice

SEE PROFILE SEE PROFILE

maria jose Güerre María Serrano Villar

SEE PROFILE SEE PROFILE

Clinical high-risk (CHR) for psychosis View project

Canine psychotherapy View project

The user has requested enhancement of the downloaded ﬁle.

2 Adapting the Brief Coping Cat to a Group Setting in the Spanish

6 María Serrano-Villar5 José Carlos Espín-Jaime1 Miguel Ángel Jiménez-Arriero1

26 anxiety disorder Social phobia

Anxiety disorders are the most prevalent disorders among 28

et al. 2010). Anxiety disorders occur early in life, with the 30

disorder (GAD) is the most prevalent child disorder in 33

78 individual treatment (16 sessions; Kendall et al. 1997; insufﬁcient. 131

in a certain way to prevent bad things from happening”); 331

472 Descriptive Statistics

Table 1 Baseline differences in

Gender (male) 6 (42.9) 11 (73.3) 2 (50.0) 2.86 0.239 0.29

*Indicates which groups differ

Table 2 Change between pre-

n varies between variables due to missing data

Table 4 Differences between measures reported by parents (n = 26)b

STAI-trait 20.8 7.2 22.3 8.5 0–20 0.65 0.527 0.16

STAI-state 18.4 10.5 17.5 8.5 0–20 0.59 0.566 0.15

STAI-trait 21.3 8.6 20.7 8.2 0–20 0.55 0.594 0.14

M mean, d Cohen’s d, t t-test, p p-value

Albores-gallo, L., Lara-Muñoz, C., Esperón-Vargas, C., Cárdenas, J. 972

inner workings. Cognitive and Behavioral Practice, 20(2), 988

View publication stats

Vous aimerez peut-être aussi