Effectiveness of CBT for anxiety disorders in mental health clinics and in schools as indicated prevent. Jon Bjåstad et al. Anxiety Disorders Research Network, Haukeland University Hospital, Norway

1. Effectiveness of CBT for anxiety
disorders in mental health clinics and
in schools as indicated prevention
Bjåstad JF1, Wergeland GJH1,2, Høye, A3, Fjermestad KW1,2,
Haugland B1,4, Oeding, K1, Öst LG 1,5, Havik O 1,2, Heiervang ER, 1,6.
1 Anxiety Disorders Research Network, Haukeland University Hospital, Norway
2 University of Bergen, Norway
3 Fjell Municipality, Norway
4 Uni Research, Norway
5 Stockholm University, Sweden
6 University of Oslo, Norway

2. Background
• The effect of CBT for childhood anxiety disorders is well
documented in university clinic settings
• Results may not be valid in regular outpatients clinics
– Recruited vs referred children
– Homogenous sample
– Differences in therapist training
• Few effectiveness studies in clinical settings
• Few effectiveness studies on the use of CBT as indicative
prevention in the school health system

3. Study questions:
1. Is ”FRIENDS for life” effective for the treatment of anxiety for
children and adolescents in an outpatient setting?
2. Is ”FRIENDS for life” effective as an indicated prevention
program in a school/youth health center setting?

4. Assessment and Treatment- Anxiety in
Children and Adults (ATACA)
A randomized, controlled, multisite, effectiveness study
of the CBT programme ”Friends for life”.
PI Einar R. Heiervang, Professor
PI Odd E. Havik, Professor
Grant from Western Norway Regional Health Trust

5. Study sites
No of clinics: 7
No of therapists: 16
No of assessors: 16

6. Methods
Participants
• 8-15 year olds, ordinary referrals with a primary anxiety
disorder diagnosis

7. Methods
Inclusion/Exclusion
• Inclusion
– Separation (SAD), Social (SOP), or Generalised (GAD) anxiety
disorder. (ADIS-C/P; CSR>=4)
• Exclusion
– Autism spectrum disorder
– Intellectual disabilities
– Obsessive-compulsive disorder
– Severe conduct problems
– Unstable medication

8. Methods
Intervention
• Friends for Life, 4th ed (Barrett; 2004, 2005)
– Group and Individual format
– Child (8-12) and Youth (12-15) versions
F - feeling worried ?
R - relax and feel good
I - inner thoughts
E - explore plans
N - nice work so reward yourself
D - don’t forget to practice
S - stay calm, you know how to cope now

9. Methods
Measures
• Anxiety Disorders Interview Schedule
– (ADIS IV-C/P; Silverman & Albano, 1996)
• Spence Children’s Anxiety Scale
– (SCAS; Spence, 1995)
• Short Mood and Feelings Questionnaire
– (SMFQ; Angold et al., 1995)

10. Sample characteristics
Total sample N=182
M (SD) %
Gender
Male 47,0 %
Female 53,0 %
Age (mean, SD) 11.54 (2.08)
Age group
8-12 yrs 66,0 %
12-15 yrs 34,0 %
Comorbidity present 77,5 %
Primary diagnosis
SAD 33,0 %
SOP 46,0 %
GAD 21,0 %

11. Is ”FRIENDS for life” effective for the
treatment of anxiety for children and
adolescents in an outpatient setting?
Results

12. Active treatment vs wait list
80,0 %
70,0 %
60,0 %
50,0 %
43,3 %
40,0 % Post treatment
After Wait list
31,1 %
30,0 %
20,0 %
13,9 %
10,0 %
2,8 %
0,0 %
No longer primary diagnosis No anxiety diagnosis

13. Group- vs individual treatment
100 %
90 %
80 %
70 %
60 %
50 %
50 %
Group
40 % 38 % 38 %
Individual
30 % 25 %
20 %
10 %
0%
No longer primary diagnosis No anxietydiagnosis

14. Diagnostic Recovery Rates
• By age
– Children 41%
– Adolescents 38%
• No statistically significant differences with respect to age
group/treatment format an diagnostic recovery rates

15. SCAS and SMFQ
• Moderate effect sizes found for
– SCAS self-report
– SCAS parent report
• Moderate effect sizes found for
– SMFQ self report
– SMFQ parent report
• No statistically significant differences between ICBT and
GCBT on SCAS and SMFQ

16. Conclusions
• CBT is effective in the treatment of anxiety with children and
adolescents in ordinary outpatient clinics.
• No significant effect found for treatment format post-treatment
(group versus individual).
• Dropout rate lower than in ordinary outpatient clinics.

17. An early school-based group intervention for
youths with anxiety and depression
symptoms
A study of the CBT programme ”Friends for life”.
in Fjell Municipality, Norway

18. Methods
Participants
• 36 children/ adolescents from 8 schools with anxiety
and/or depression symptoms
• Ages 8-15 yrs old (M= 11.8)
• 12 boys and 24 girls
Recruitment
• Recruited through contact with the school health-service
or psychologist working in the municipality

19. Methods
Measures
• Spence Children Anxiety Scale; SCAS (Spence,1998).
• The Mood & Feelings Questionnarie; MFQ (Costello &
Angold, 1988).
• The Strength and Difficulties Questionnarie; SDQ
(Goodman,1997).

20. Methods
Design
• Open non-randomization study.
• Included 3 months follow up (only child report)
Intervention groups
• Total of 4 ”FRIENDS for life” groups
• 2 in primary school, 1 in secondary school and 1 at a
Youth Health Centre.

21. SCAS
40
35
30
SCAS total Score
25
20 Parents
15 Children
10
5
0
Pre Post 3 mnt

22. MFQ
25
20
MFQ total score
15
Parents
10
Children
5
0
Pre Post 3 mnt

23. Conclusions
• The “FRIENDS for life” program was effective in reducing anxiety
and depression symptoms in this sample
• The children and adolescents reported that they liked participating in
the groups, and dropout-rate was low (8%).
• The school health service can be an important arena for
implementing CBT as indicated prevention

24. Implications
• ”FRIENDS for life” is effective in regular
mental health clinics and as an indicated
prevention program in the school health
service system.

25. Limitations
• Preliminary results
• Limited sample size
• No follow up

26. Thank you
email: bjaastad@gmail.com

27. Project Group – ATACA study
• Einar R. Heiervang, Professor, University of Oslo
• Odd E. Havik, Professor, Institute of Clinical Psychology, University of Bergen.
• Bente S. Haugland, Dr. Psychol. Centre for Child and Adolescent Metal Health, Western Norway
• Kristin Oeding, Cand. Psychol. Institute of Clinical Psychology, University of Bergen
• Gerd Kvale, Professor, Institute of Clinical Psychology, University of Bergen.
• Jon F. Bjåstad, Doctor of Clinical Psychology, Clinical supervisor
• Gro Janne H. Wergeland, Cand. Med., PhD-student, Insitute of Clinical Medicin, University of
Bergen.
• Krister W. Fjermestad, Cand. Psychol, PhD- student, Institute of Clinical Psychology, University
of Bergen.
• Lars G. Öst, Professor, Institute of Clinical Psychology, University of Bergen/ Stockholm
University.
• Robert Goodman, MD PhD, professor, Institute of Psychiatry, King's College London.

28. Timeframe ATACA study: Child part
2007 2008 2010 2015
Clinical trials Main study 182 pts End of 5 year
Instruments inclusion included follow-up
Pilot Last treatment assessment
by 02/2011.
2006 2011
Organization End of 1 year
Design follow-up
Recruitment assessment

29. Flow Chart
Invited
N=258
Assessed for eligibility
N=222
Enrollment
N= 182
Randomisation
Group Individual WL N= 38
N=77
N= 67
Assessment and
Post-treatment assessment re-
randomisation
Group N= Individual
21 N= 14
Post-treatment assessment
1-year follow-up assessment
5-year follow-up assessment