Critically evaluate the FRIENDS intervention in the treatment of anxiety in childhood (1500 word limit)

The FRIENDS intervention scheme is a family-based group cognitive behavioural therapy (FGCBT) aimed at children 6-16 years old with symptoms of anxiety. As with other forms of CBT, it encourages exposure to anxiety-provoking situations, learning relaxation techniques, and forming cognitive strategies to re-work maladaptive thought attributions (Shortt, Barrett and Fox, 2001). The program also promotes the formation of peer support networks among children and parents in the scheme, allowing families to learn from each others' experiences and create new friendships. Contrary to some other types of CBT, FRIENDS is aimed at children, with different programs for age groups 6-11 years and 12-16 years, and also involves children's parents in the treatment, through teaching partner-support strategies, reinforcement techniques and encouraging daily practice of skills learned on the course (Shortt, Barrett and Fox, 2001). The program typically consists of ten weekly sessions for children, lasting 70mins and carried out during school time. The parent component is typically ten weekly 40min sessions, largely carried out on weekends when parents are more available. Studies have shown that children on the FREINDS programme have fewer symptoms of anxiety post-treatment, and also less compared to wait-list controls (Lowry-Webster, Barrett and Lock, 2003; Farrell, Barrett and Claassens, 2005). The number of children who meet criteria for an anxiety disorder is significantly less than children who did not receive the intervention, such as Shortt, Barrett and Fox's (2001) study, which found 69% of children with an anxiety disorder at the beginning of the FRIENDS programme were diagnosis free post-treatment, compared to 6% of wait-list controls. These findings clearly show a positive effect of the treatment on childhood anxiety, and such results are consistent across different cultural groups (Barrett, Sonderegger, and Xenos, 2003). Gains are also maintained beyond completion of the course, with 68% of children with a previous diagnosis of anxiety remaining sub-clinical 12 months on (Shortt, Barrett and Fox, 2001). However, the benefits derived from the programme may have an expiry date. A study by Barrett et al. (2006) showed less anxiety in 9-10 year olds on the FRIENDS scheme at 12 and 24 months after treatment compared to controls, but not after 36 months. Although reducing clinical levels of anxiety is a desirable aim in itself, it may be difficult to justify the use of the FRIENDS intervention in the current, rather arid, economic climate if long term benefits cannot be preserved. The study also suggested important age and gender effects, as 14-16 year olds showed no significant difference in symptom reduction between treatment conditions, and boys were less responsive than girls to the programme (Barrett et al., 2006). These findings could relate to the effectiveness of treatment on vulnerable groups, as the greatest decreases in anxiety were found in the children most anxious pre-treatment, which also corresponds to younger children and girls (Barrett, Rapee and Dadds, 1996). The FRIENDS scheme therefore seems most useful for high-risk groups, notably children in early secondary school (but not adolescents) and young girls. It may be a valuable tool in reducing anxiety in these groups at a critical period, even though the advantages (based on symptom and diagnosis prevalence) compared no treatment is minimised over time. An important aspect of FRIENDS is its involvement of parents within the treatment. A common barrier to therapy in children is the (lack of) support they receive at home, as parents are key in encouraging adaptive behaviour, motivating their child and providing opportunities for skill practice (Stallard, 2009). Not only does the FRIENDS programme try and address these issues by educating parents about the scheme and how to support their children, it also targets parental behaviour that may be contributing to their child's anxiety (Shortt, Barrett and Fox, 2001). Studies have shown parents can have a negative influence on children's evaluation of threat (Dadds et al., 1996) and may 'enhance' the anxious cognitions of their already clinical children (Barrett et al., 1996). Family-based CBT (CBT+FAM) has been shown to be more effective than CBT with only

the child involved (Barrett, Rapee and Dadds, 1996), however again the gains were limited to younger children. Girls showed greater reductions in anxiety when the family component was included and boys did equally well in both CBT and CBT+FAM conditions. This supports the usefulness of the FRIENDS' family component for girls and younger children, however it cannot be advocated over CBT alone when used on boys or older children only. Regardless of outcome, the FRIENDS programme has been consistently rated as enjoyable, useful and worthy of recommendation, by both parents and children (Shortt, Barrett and Fox, 2001). This in itself is an aid to treatment, as children who are disinterested in their treatment scheme are unlikely to benefit from it (Stallard, 2009). At the same time, these results may be misleading. One of the advantages of CBT over other therapies is that the goals of treatment are largely defined by the patient, who works in partnership with the therapist to achieve them (Mansell, 2008). However, this is one area of research significantly lacking in the literature. The author has not come across any paper on FRIENDS measuring the outcome of the programme by client goal completion, only on relative reductions in symptomatology. This means there is no way to verify to what extent children and parents on the programme were able to achieve their own targets, which is arguably one of the most important aims of FRIENDS. Related to this is the inability of current methods of CBT to appreciate the 'human condition' because of the concept's resistance to scientific investigation (Woolfolk and Richardson, 2008). It includes ideas such as a meaningful identity from art, literature and religion, and the search for meaning within life and a meaningful existence. Kobasa (1979) found evidence to support the view that concepts such as a sense of meaningfulness and a connection with the environment can mitigate the effects of a stressful situation and help the individual cope anxiety-provoking circumstances. CBT, as a set of techniques for finding the most effective means to an end, not the means themselves, is ill-prepared to address ideas such as a meaningful life, which seems to be a core part of psychological well-being (Zika and Chamberlain, 1992). Even the study just quoted is only able to establish a relationship between meaning and happiness, not the meaning itself, which is a distinct flaw in the current scientific method. As meaning in life is related to long-term positive mental health, the FRIENDS scheme might be able to increase the length of time gains are maintained through the incorporation of a 'meaning' component into its programme.

Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. R. (2006). Long-Term Outcomes of an Australian Universal Prevention Trial of Anxiety and Depression Symptoms in Children and Youth: An evaluation of the Friends program. Journal of Clinical Child and Adolescent Psychology, 35(3), 403-411. Barrett, P. M., Rapee, R. M., & Dadds, R. M. (1996). Family Treatment of Childhood Anxiety: A Controlled Trial. Journal of Consulting and Clinical Psychology, 64(2), 333-342. Barrett, P. M., Rapee, R. M., Dadds, R. M., & Ryan, S. (1996). Family enhancement of cognitive style in anxious and aggressive children. Journal of Abnormal Child Psychiatry, 24(2), 187-203. Barrett, P. M., Sonderegger, R., & Xenos, S. (2003). Using Friends to Combat Anxiety and Adjustment Probles among Young Migrants to Australia: A national trial. Clinical Child Psychology and Psychiatry, 8(2), 241-260. Dadds, R. M., Barrett, P. M., Rapee, R. M., & Ryan, S. (1996). Family Process and Child Anxiety and Aggression: An observational analysis. Journal of Abnormal Child Psychiatry, 24(6), 715-734.

Farrell, L. J., Barrett, P. M., & Claassens, S. (2005). Community Trial of an Evidence-Based Anxiety Intervention for Children and Adolescents (the FRIENDS Program): A pilot study. Behaviour Change, 22(4), 236248. Lowry-Webster, H. M., Barrett, P. M., & Lock, S. (2003). A Universal Prevention Trial of Anxiety Symptomology during Childhood: Results at 1-year follow-up. Behaviour Change, 20(1), 25-43. Kobasa, S. C. (1979). Stressful Life Events, Personality and Health: An inquiry into hardiness. Journal of Personality and Social Psychology, 37(1), 1-11. Mansell, W. (2008). What is CBT really, and how can we enhance the impact of effective psychotherapies such as CBT? In R. House & D. Lowenthal (Eds.), Against and For CBT: Towards a constructive dialogue? (pp. 19-32). Herefordshire: PCCS Books Ltd. Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the FRIENDS Program: A cognitivebehavioural group treatment for anxious children. Journal of Clinical Child Psychology, 30(4), 525535. Stallard, P. (2009). Anxiety: Cognitive behavioural therapy with children and young people. Hove: Routledge. Woolfolk, R. L., & Richardson, F. C. (2008). Behavioural therapy and the ideology of modernity. In R. House & D. Lowenthal (Eds.), Against and For CBT: Towards a constructive dialogue? (pp. 5271). Herefordshire: PCCS Books Ltd. Zika, S., & Chamberlain, K. (1992). On the relations between meaning in life and psychological wellbeing. British Journal of Psychology, 83(1), 133-145.