A Universal Prevention Trial of Anxiety Symptomology during Childhood: Results at 1-Year Follow-up

A number of published studies have provided empirical support for both individual and group CBT treatment as being more effective than a waitlist condition for reducing anxiety when implemented by extensively trained and supervised clinicians, (Barrett, Dadds, & Rapee, 1996; Barrett, 1998; Cobham, Dadds, & Spence, 1999; Dadds, Holland, Barrett, Laurens, & Spence, 1997; Flannery-Schroeder & Kendall, 2000; Mendelowitz et al., 1999; Kendall, 1994; Kendall et al., 1997; King et al., 1998; Last, Hanson, & Franco, 1998; Shortt, Barrett, Dadds & Fox, 2001; Silverman et al., 1999). These independent clinical trials indicate that anxiety disorders in late childhood and early adolescence can be effectively treated. Yet of those in need of mental health services, less than 20% receive appropriate care, with children in need not being reached, long waiting lists and noshow rates and family dropouts sometimes exceeding 50% (Day & Roberts, 1991; Tuma,1989; Weist, 1999; Zubrick et al. 1997).

Subsequently, over the last few years, prevention has been touted as the most important direction for researchers and clinicians to focus on in dealing with anxiety disorders during childhood and adolescence (Dadds et al., 1997; King, Hamilton, & Murphy, 1983; Munoz, 2001; Spence, 1994; Spence, 2001). Controlled preventive interventions are only slowly beginning to emerge. For example Dadds, Spence, Holland, Barrett, and Laurens (1997), conducted the first controlled prevention trial with a community cohort of anxious children. This project employed a combined indicated1 and selective2 approach to the development of anxiety disorders in young people. We aimed to provide a comprehensive coverage of children, including those who were disorder free but showed mild anxious features, through to children who met diagnostic criteria for an anxiety disorder, but at a low level of severity. Immediately following completion of the program, no significant differences were evident between the two groups. However, at 6-month followup, the results demonstrated not only a significant reduction in existing anxiety, but also a prevention effect, where 58% of children in the monitoring group progressed to a diagnosable disorder, compared to only 16% of the intervention group. Moreover, even at 24 months follow-up these improvements were maintained in the intervention group only (Dadds, Holland, Barrett, Laurens, & Spence, 1999). Examination of predictors of chronic anxiety showed that being female and parental anxiety were predictive of an anxiety disorder at posttreatment, while children with high levels of internalising symptoms at pretreatment and children in the monitoring group were more likely to have an anxiety disorder at posttreatment and at 2-year follow-up.

Overall, these results are promising, particularly given the design of the study (randomized trial) and the use of diagnostic classifications as outcome measures. As such, this trial demonstrated that anxiety disorders can be ameliorated and prevented, avoiding the high levels of subjective distress for individuals and their families, and the negative long-term consequences in terms of disruption to relationships, schooling and vocational development. Similarly the few other selective based prevention programs reported in the literature with internalising problems in young people (i.e., depression: Jaycox, Reivick, Gillham,& Seligman, 1994; and shyness in preschoolers: La Frenier & Capuano, 1997) also found positive results when implemented by specialist staff. Despite these encouraging results, this model of prevention has a number of limitations inherent in its design. That is, a labelling or stigmatising effect may have been created because the studies were based on identifying individuals “at risk” for anxiety or depression, and therefore may run contrary to the intention of promoting children’s self confidence and esteem. Further, the Jaycox et al. (1994) study encountered difficulties in recruiting and maintaining the attendance of participants as the program was implemented outside of normal disorder, but at a low level of severity. Immediately following completion of the program, no significant differences were evident between the two groups. However, at 6-month followup, the results demonstrated not only a significant reduction in existing anxiety, but also a prevention effect, where 58% of children in the monitoring group progressed to a diagnosable disorder, compared to only 16% of the intervention group.

A Universal Prevention Trial of Anxiety and Depressive Symptomatology in Childhood: Preliminary Data from an Australian Study

Prevention has been touted as the most important direction for researchers and clinicians to focus on in dealing with anxiety disorders during childhood and adolescence (Spence, 1994). It is now widely accepted that anxiety disorders are the most common form of psychological distress self-reported throughout this period of the lifespan (Ollendick & King, 1998). Indeed, current estimates of the prevalence of anxiety in children are alarming. Recent research suggests that around one in six children experience anxiety severe enough to interfere with their daily functioning (Boyd, Kostanski, Gullone, Ollendick, & Shek, in press; Dadds, Spence, Holland, Barrett, & Laurens, 1997). Beyond the high prevalence rates, anxiety disorders are associated with a wide range of psychosocial impairments (Last, Hanson, & Franco, 1997; Mattison, 1992). They have also been identified as significant risk factors for other disorders, particularly other anxiety disorders and depression (Cole et al., 1998; Orvaschel, Lewinsohn, & Seeley, 1995) and tend to be stable during childhood and adolescence, continuing into adulthood if left untreated (Cantwell & Baker, 1989; Keller, Lavori, Wunder, Beardslee, & Schwartz, 1992).

In addition to the personal suffering experienced by children and their families, anxiety disorders also have a tremendous cost to society. According to a study sponsored by the Anxiety Disorders Association of America, anxiety disorders cost the nation more that $42 billion dollars a year (Greenburg et al., 1999). Australia is likely to evidence a similar pattern of expense, with more than half of this cost associated with the repeated visits to health care services, with sufferers attempting to seek relief from anxiety symptoms that frequently mimic physical illnesses. Taken together, these factors are powerful forces in prompting researchers to develop ways to best intervene, reduce, or remediate the cognitive, behavioural, and emotional difficulties associated with anxiety. Previous research has consistently shown that anxiety disorders in late childhood and early adolescence can be effectively treated using brief psychosocial interventions. In 1994, Kendall conducted the first published randomized clinical trial of cognitive-behavioural treatment (CBT) with 47 anxious children aged 9 to 13 years. Sixty-four per cent of the children who completed the treatment program (The Coping Cat Program; Kendall, 1990) were diagnosis free at posttreatment, and these improvements were maintained at 12-month follow-up.

Barrett, Dadds, and Rapee (1996) demonstrated similar effects with 79 anxious children aged between 7 to 14 years. They compared a CBT intervention based on Kendall’s Coping Cat program (1990) with a CBT plus family condition (FAM). At posttreatment, 61% of children in the CBT group no longer met a diagnosis, compared with 88% in the CBT plus FAM treatment, and less than 30% in the waiting-list control group. Moreover, 5 to 7 years later, at long-term follow-up, 85.7% no longer fulfilled diagnostic criteria for any anxiety disorder, with CBT and CBT plus FAM being equally effective (Barrett, Duffy, & Dadds, in press). These findings clearly demonstrate the extended treatment effects and long-term clinical utility of cognitivebehavioural therapy in treating children suffering from anxiety disorders. Recently, the effectiveness of these treatment programs has been further demonstrated when presented in a group format. For example,in a recent study conducted by Shortt, Barrett, and Fox (in press), 91 clinically anxious children ranging from 6 to 14 years old were randomly allocated to a family-based group cognitive behavioural treatment (FGCBT using the FRIENDS program) or a waiting-list control group. The FRIENDS program originated with the development of the Coping Cat (Kendall, 1990) and the Australian version, called the Coping Koala (Barrett, 1995) (see Barrett, 1998 for a complete developmental review). Results indicated that 68% of children who completed FGCBT were diagnosis free, compared to 14% of children on the waiting list. At 12-month follow-up, 76% of children were diagnosis free. Other studies examining the effectiveness of group CBT programs for anxiety have demonstrated similar effects (e.g., Barrett, 1998; Cobham, Dadds, & Spence, 1998; Mendolowitz et al., 1999; Silverman, Kurtines, Ginsburg, & Weems, in press).

A Longitudinal Study of Developmental Differences in Universal Preventive Intervention for Child Anxiety

Research in child anxiety disorders indicates prevention of this problem is an important area warranting further investigation (Donovan & Spence, 2000). Clinical trials provide empirical support for cognitive-behavioural therapy (CBT) in individual, group and family format (Barrett, Dadds, & Rapee, 1996; Barrett, 1998; Kendall, 1994; Silverman, Kurtines, Ginsburg, Weems, Lumpkin et al., 1999; Silverman, Kurtines, Ginsburg, Weems, Rabian et al.,1999). Recent research advances have focused on preventive intervention by examining the effects of clinically-developed CBT programs in reducing the risk, onset and development of anxiety disorders within community settings (Barrett & Turner, 2001; Dadds, Spence, Holland, Barrett, & Laurens, 1997; Dadds et al., 1999; Lowry-Webster, Barrett, & Dadds, 2001).

Prevention programs have traditionally been defined on the basis of their position of the target sample along the developmental continuum of psychopathology (Mrazek & Haggerty, 1994). Primary preventive interventions can be defined as either universal, selected or indicated (Mrazek & Haggerty, 1994). Universal interventions target whole population groups, selective interventions involve young people identified as at risk of psychological problems and indicated interventions target individuals identified with mild to moderate symptoms of a disorder (Mrazek & Haggerty, 1994). Universal schoolbased prevention interventions have many advantages as they specifically target a broad range of young people with varying levels of psychopathology, ranging from those with clinical (severe) or subclinical (moderate) symptoms, to those at risk of a disorder. By targeting large groups of youth within the classroom, universal school-based programs may reduce difficulties with recruitment, screening, transportation, and stigmatisation often associated with treatment programs conducted within clinical settings. Beyond this, universal prevention has the potential to enhance peer support, and reduce psychosocial difficulties within the classroom by increasing the opportunity of peer modelling of prosocial behaviour (Armburster, Andrews, Couenhoven, & Blau, 1999; Kubiszyn, 1999).

Despite the potential advantages of universal school-based prevention programs, studies evaluating such programs for child anxiety are sparse. The Queensland Early Intervention and Prevention of Anxiety Project (QEIP; Dadds et al., 1997; Dadds et al., 1999), utilised a “selective” intervention involving 128 children at risk of an anxiety disorder. Children were randomly allocated to either an intervention group or a monitoring group. The intervention group participated in a 10-week 2-hour CBT intervention (The Coping Koala; Barrett, Dadds, & Rapee, 1991) conducted by psychologists after school hours. Results showed that all children reported decreases in anxiety over time. At 6-month and 2-year follow-up intervals, a preventive effect was demonstrated with significantly fewer participants in the intervention group meeting criteria for an anxiety disorder compared to the monitoring group. In terms of gender, this study demonstrated that being female was a predictor of treatment outcome at 2-year follow-up. Overall, the results of this study suggest that selective school-based preventative intervention has the potential to reduce the prevalence of child anxiety disorders within the community, and decrease the high levels of subjective distress for individuals and their families. However, a major limitation of this study was its selective design, therefore enabling a possible labelling or stigmatisation effect which can occur through the process of identification, selection, and participation of children “at risk” of anxiety in such programs out of school hours.

To overcome the limitations inherent in selective designs, Lowry-Webster et al. (2001) examined the effectiveness of a universal CBT intervention for child anxiety, implemented by trained teachers and school counsellors as part of the school curriculum. Participants were 594 children aged between 10 and 13 years who were allocated on a class-by-class basis to either a 10-week CBT (Barrett, Lowry-Webster, & Turner, 2000a, 2000b) intervention or monitoring condition, and further divided into high risk and healthy groups based on self-reported anxiety scores. Results were examined universally (for all children), and for children who scored above the clinical cut-off for anxiety on their pre-intervention self-report measures. All children reported significant decreases in anxiety, although these reductions were significantly greater in the intervention group compared to the monitoring condition. Positive results were found for changes in risk status, where 75.3% of the children identified at-risk in the intervention group were no longer at risk at post-intervention, compared to 54.8% of at-risk children in the monitoring group. Intervention effects were maintained at 12-month follow-up (Lowry-Webster, Barrett, & Lock, in press), with 85% of children at risk of anxiety and depression diagnosis-free, compared to only 31.2% of children in the control group. Interestingly, this study found no effects for gender. Overall, these results suggest that teacher-implemented preventive intervention is potentially effective in reducing symptoms of anxiety in children at risk of a clinical disorder.

Community Trial of an Evidence-Based Anxiety Intervention for Children and Adolescents (the FRIENDS Program): A Pilot Study

Anxiety is one of the most common psychological problems experienced during the childhood years (Mattison, 1992), with one in six children in Australia experiencing clinical levels of anxiety at any given time (Boyd, Kostanski, Gullone, Ollendick, & Shek, 2000). While the majority of children experience episodes of anxiety as part of a normal development, some children will also develop more-persistent and intense feelings of anxiety that will interfere significantly with their ability to handle a wide variety of everyday activities, including friendships with peers, academic work and family relationships (Barrett, 1998; Kashani & Orshavel, 1990). Considering the prevalence of anxiety within the community, and in light of the negative consequences for children suffering from these conditions, there is a great need for research that focuses on the effective management of anxiety during the childhood years.

It is estimated that up to 10% of children, and between 15% to 20% of adolescents, experience clinical levels of anxiety or depression (Angold & Rutter, 1992; Kashani & Orvaschel, 1990). In addition to being prevalent within the community, anxiety is also highly co-morbid, thus children with one anxiety disorder tend to have at least one other anxiety disorder. Results of an investigation with 73 children, all diagnosed with a primary anxiety disorder, showed that 80% of children met criteria for a co-morbid anxiety disorder (Last, Strauss, & Francis, 1987). It has also been found that there is a strong relationship between depression and anxiety in children and adolescents (Cole, Peeke, Martin, Truglio, & Seroczynski, 1998). Children with both anxiety and depression tend to be older than their anxious-only or depressedonly counterparts, and they also seem to be more symptomatic. The results of research suggest that children who experience anxiety during early life are at a much greater risk for the development of further anxiety and depressive disorders during adolescence and early adulthood (Pine, Cohen, Gurley, Brook, & Ma, 1998; Cole et al., 1998). The importance of developing and evaluating techniques for the treatment and prevention of anxiety during childhood is clearly highlighted by these results. Over the past 10 years, researchers have demonstrated that anxiety disorders in childhood can be successfully treated with relatively brief psychosocial interventions.

A number of studies undertaken across the past decade have indicated that cognitive–behavioural treatment (CBT) for children is effective in reducing anxiety (Kendall, 1994; Barrett, Dadds, & Rapee, 1996; Last, Hansen, & Franco, 1998). These CBT interventions typically contain a collection of techniques, including exposure (systematic desensitisation), modelling, operant conditioning, cognitive restructuring and problem-solving strategies (Barrett, 2000). Kendall (1994) conducted the first randomised treatment study of anxiety disorders in children in a trial that involved 47 children aged between 9 to 13 years with either a separation anxiety disorder, overanxious disorder or an avoidant disorder. These children were randomly allocated to either a treatment program or a waitlist condition.

The treatment used in this study was a CBT program called Coping Cat, the development of which was based on the assumption that anxiety manifests itself at physiological, behavioural and cognitive levels (Kendall et al., 1991). Results of this study showed that 64% of the children in the treatment group were diagnosesfree at posttreatment, whereas only 1 child in the waitlist condition was diagnosisfree at the completion of the project.Barrett et al. (1996) later extended this work by evaluating a family-based CBT program for childhood anxiety. The CBT program utilised in this study was adapted from the American Coping Cat program and was subsequently named the Coping Koala program, and was for use with Australian samples. A total of 79 children aged 7 to 14 years who fulfilled diagnostic criteria for separation anxiety, overanxious disorder or social phobia were randomly assigned to one of the following three conditions: (a) CBT program, (b) CBT program plus family component, or (c) waitlist. Results indicated that 69.8% of the children in both of the treatment groups (CBT or CBT + family) no longer fulfilled criteria for an anxiety disorder, compared with only 26% of children in the waitlist condition. At 12-month follow-up, 70.3% of the children in the CBT group and 95.6% of the children in the CBT plus family condition no longer fulfilled criteria for an anxiety disorder. The results of this study demonstrate the added long-term benefits of implementing a family management component (e.g., providing parental training, improving family problem-solving) in addition to CBT for children with anxiety. In addition, a long-term follow-up study with 52 of these children was conducted 5 to 7 years later, with results indicating that 85.7% of the children who completed the
CBT program did not meet criteria for an anxiety disorder (Barrett, Duffy, Dadds, & Rapee, 2001). These findings add further support to the utility of CBT for the effective and long-term management of childhood anxiety. While such results provide support for the use of individual CBT for childhood anxiety, the efficacy of using CBT in a group-based format has also been investigated recently in controlled clinical trials (Barrett, 1998; Shortt, Barrett, & Fox, 2001; Silverman, et al., 1999).

Prevention and Early Intervention for Anxiety Disorders: A Controlled Trial

There is growing evidence to suggest that anxiety disorders in childhood and adolescence are significant and warrant more attention from researchers and clinicians. Anxiety disorders are the most common form of psychological distress reported by children and adolescents (Garralda & Bailey, 1986; Kashani, Orvaschel, Rosenberg, & Reid, 1989; Viken, 1985), tend to be stable through childhood and adolescence unless treated (Cantwell & Baker, 1989), and are associated with a range of psychosocial impairments (Mattison, 1992). Thus, although childhood can be expected to include transient fears and anxieties, a significant proportion of children will develop anxiety problems predictive of generalized and long-term impairment if left untreated.

Recently, controlled trials have demonstrated the effectiveness of psychosocial interventions for child and adolescent anxiety disorders. Kendall (1994) evaluated the effectiveness of a cognitive-behavioral therapy (CBT) program for 9- to 13-year-old children with overanxious, separation, and social anxiety disorders.

Compared with a wait-list control, the treated children showed clinically significant gains that were maintained over an average follow-up period of 3.5 years (Kendall & Southam- Gerow, 1996). A second outcome study has shown similar effects (Kendall, Flannery-Schroeder, et al., 1997). Barrett, Dadds, and Rapee (1996) compared a CBT intervention based on Kendall’s (1990) program to an intervention that included the CBT intervention plus a family intervention, for a mixed group of 7- to 14-year-olds with overanxiety, separation anxiety, and social phobia disorders. Both interventions achieved a nodiagnosis status (that is, no existing diagnosis) in over 60% of children at posttreatment compared with less than 30% of children on the wait-list. At the 12-month follow-up, no-diagnosis rates were 70% and 95% for the CBT and CBT + family intervention groups, respectively. These clinical trials indicate that anxiety disorders in late childhood and early adolescence can be effectively treated. However, tertiary treatments may not be the most effective or efficient method for managing child psychopathology and behavior disorders (Kazdin, 1987). Early intervention and prevention programs aimed at larger cohorts of children in community settings have the potential to be more cost-effective in reducing the overall incidence of childhood disorders and their cost to the community. Although no such work with community cohorts of anxious children has been reported, a number of authors (King, Hamilton, & Murphy, 1983; Spence, 1994) have discussed the potential of such programs for children at risk for the development of anxiety disorders. A critical issue in the design of preventive programs is the choice of criteria for selection of at-risk children. To be exclusively “preventive” in focus would exclude children already showing anxiety problems from the benefits of early intervention. On the other hand, previous research has documented effective treatments for children with severe disturbance (Barrett et al., 1996; Kendall, 1994). Thus, the Queensland Early Intervention and Prevention of Anxiety Project (QEIPAP; Dadds & Spence, 1994) combined a preventive with an early-intervention approach to managing the development of anxiety disorders in young people. The aim was to intervene for children, from those who were disorder-free but showed mild anxious features to those who met criteria for an anxiety disorder but were in the less severe range. These children are henceforth referred to as at risk.

Three tools are required to mount effective prevention or early intervention programs: (a) an identification strategy (screen) that reliably identifies children at risk; (b) an access point where such children can be identified; and (c) an intervention procedure that can be implemented without major cost to the clientele or the mental health system. For anxiety disorders, these requirements are partly in place. Child and parental report measures are available that offer moderate accuracy in identifying children with, or at risk for, anxiety problems (King, Hamilton, & Ollendick, 1988; Laurent, Hadler, & Stark, 1994; Perrin & Last, 1992), and the Anxiety Disorder Interview Schedule (ADIS; Silverman & Nelles, 1988) reliably identifies children with specific anxiety disorders as listed in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; DSM-HI-R; American Psychiatric Association, 1987; Rapee, Barrett, Dadds, & Evans, 1994). Although existing measures may be of limited validity in their ability to discriminate anxiety problems from other behavior problems in children (Perrin & Last, 1992), the use of multiple informants and measures can be used to reliably identify children at risk for anxiety problems. School systems can provide access points to the cohorts of children in appropriate age ranges for the identification of children at risk, and intervention programs are available that have been shown to reduce anxiety problems when implemented with groups of children with established anxiety disorders (Barrett, Dadds, Rapee, & Ryan, 1993). This program used reports from teachers and children accessed in the school system to identify at-risk children and used a combined social learning/family approach to intervention within a randomized design. We were interested in designing a program that could be easily and effectively mounted in most school settings and that would meet the needs of the majority of children at risk for anxiety problems (i.e., was comprehensive). Most anxiety problems in children emerge in late childhood, and at least this level of maturity is needed for children to benefit from cognitively focused psychotherapies. Thus, the primary school age group of 7- to 14-yearolds was selected as our target population.
The overall aim of the present study was to evaluate an early intervention and prevention program. The specific aims were to examine the remediating effects of the intervention on children’s functioning at postintervention and at 6-month follow-up, in comparison with a no-intervention monitoring group. It was hypothesized that the intervention would be associated with lower rates of anxiety problems and disorders, compared with nonintervention, postintervention, and 6-month follow-up, as measured by diagnostic interviews with parents and standardized self-report forms.

Anxiety problems are the most common form of psychological distress reported by children and adolescents (Garralda & Bailey,1986; Kashani, Orvaschel, Rosenberg, & Reid, 1989; Viken, 1985). However, increasing evidence points to the amenability of these problems to psychosocial intervention. Evaluations of Kendall’s (1994) program for 9- to 13-year-old children with overanxious, separation, and social anxiety showed that clinically significant gains can maintain over an average follow-up period of 3.5 years (Kendall & Southam-Gerow, 1996). A second outcome study has shown similar effects (Kendall et al., 1997). Barrett, Dadds, and Rapee (1996) compared a cognitive-behavioral intervention based on Kendall’s (1990) program with an intervention that also included a family intervention, again for a mixed group of overanxious, separation-anxious, and socially phobic 7- to 14- year-olds. Both interventions achieved a no-diagnosis status in over 60% of children at posttreatment compared with less than 30% of children on the wait list, and the effects were maintained at 12-month follow-up. Using controlled trials, both Barrett (in press) and Cobham, Dadds, and Spence (1998) have shown that similar success rates can be obtained by presenting the intervention in a cost-effective group format rather than in an individual format. Inspired by these successes, the Queensland Early Intervention and Prevention of Anxiety Project (QEIPAP; Dadds, Spence, Holland, Barrett, & Laurens, 1997) aimed to evaluate the potential of these interventions to be used as preventive and early interventions. Thus, the project used a school-based screening procedure to identify, and then offer skills training to, high-risk children. The children ranged from those who were disorder free but showed mild anxious features to those who met criteria for an anxiety disorder but were in the less severe range. At pretreatment, approximately 75% of selected children who were interviewed met criteria for an anxiety diagnosis (mild to moderate severity). At postintervention, improvement was noted for both intervention and monitoring groups. Children who received the intervention emerged with lower rates of anxiety disorder at 6-month follow-up compared with those who were monitored only. Of those who had features of but no full disorder at pretreatment, 54% progressed to a diagnosable disorder at 6-month follow-up in the monitoring group compared with 16% in the intervention group. These results indicated that the intervention was successful in reducing rates of disorder in children with mild to moderate anxiety disorders, as well as preventing the onset of anxiety disorders in children with early features of a disorder. In this article, we report on the QEIPAP children at 12 and 24 months after the termination of the intervention. It was hypothesized that the intervention would be associated with lower rates of anxiety problems and disorders and higher ratings of improvement made by parents and clinicians compared with the monitoring condition at these time points. A secondary aim was to examine child and family factors that were predictive of chronicity of anxiety problems. Specifically, we tested the findings of previous research that severity of initial problems, poor parental adjustment, and, more tentatively, female gender of the child are predictive of chronic anxiety problems (Barrett et al., 1996; Cobham et al., 1998).

Psychological Management of Anxiety Disorders in Childhood
Anxiety and fear are an inherent part of the human condition. In times of danger, they are transitory and adaptive. What is interpreted as dangerous, however, changes across the lifespan. As a consequence of children’s developmental experiences and their increasing cognitive abilities, the content of normative fears and anxieties generally shifts from concerns about concrete, external things to internalised, abstract anxieties (Koplewicz, 1996). Thus, infants tend to fear strangers, loud noises, and unexpected objects, while children fear separation from their parents, animals, loud noises, the dark, and the toilet. Between the ages of 4 and 6, predominant fears include kidnappers, robbers, ghosts, and monsters. At 6 years, fears of bodily injury, death, and failure develop. These may continue into early adolescence. At 10 or 11 years of age, fears regarding social comparison, physical appearance, personal conduct and school examinations may predominate. However, anxiety can be an unpleasant feeling that arises without any obvious threat. It consists of a mixture of physiological symptoms (e.g. sweaty palms, “butterflies” in the stomach), behavioural signs (e.g. avoidance), and cognitive components (e.g. “I’m going to fail and everyone will laugh at me”). Children and adolescents who have anxiety problems experience some combination of the following: unrealistic and excessive worry about past or future events and about performance; need for reassurance; marked self-consciousness; somatic complaints with no physical cause; restlessness or feeling “keyed up” or “on edge”; fatigue; difficulty concentrating; irritability; distress on separation from parents; school refusal; panic attacks; avoidance of situations; distress in social situations; phobias; obsessions or compulsions. Recently, research hashown that many anxiety problems begin in childhood and thtahte se are a common form of psychological problem and can be highly distressing and associated with a range osfo cial impairments (Dadds, Barrett, & Cobham, 1997). Thus, skills for assessing and treating childhooadn xiety problems should be in the repertoire of all child mental health specialists. This paper presents an overview of these skills.

Types of Anxiety Disorders in Childhood
Categorical systems for classifying anxiety disorders are useful but not without problems. The individual categories have enormous overlap in specific symptoms, and even after controlling for this overlap, the majofr ity sufferers will show more than one category. Also, experiences of anxiety fall on a continuum of severity and the assignment of a disorder necessitates drawing an arbitrary cutoff on this continuum. At this point, theries precious littled ata tos how that thed ifferent child anxiety disorders are associated with different etiological, prognostic, and treatment factors. Notwithstanding, use of a diagnostic system can greatly aid clinical precision and research progress. The main categories of anxiety disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) are described below. Separation anxiety disorder (SAD) is one of the most common anxiety problems found in children and is developmentally inappropriate and excessive anxiety regarding separation from attachmentf igures in a child’s life (Silove, Manicavasagar, Curtis, & Blaszczynski, 1996). Generalised anxiety disorder (GAD) is exaggerated or uncontrollable anxiety, physiological arousal, and/or worry about events (Masi, Mucci, Favilla, Romano, & Poli, 1999). It is characterised by selfconsciousness, sleep disturbance, excessive reassurance seeking, and worry about future (e.g. going to see a doctor) or past events (e.g. something the person said), and anxiety about performance and competence. Specific phobias (SP) are characterised by marked fear of a specific feared object or situation that is not a realistic threat (N. J. King, Hamilton, & Ollendick, 1998). Social phobia (SocP) is characterised by fear of embarrassment and anxiety when exposed to social or performance situations (e.g. going to parties, speaking in front of a group). Children with social phobia avoid feared situations or, if necessary, endure them with intense anxiety. Panic attacks are discrete periods in which there is a sudden onset of intense apprehension, fearfulness, or terror, often associated withfe elings of impending doom, that occur outside of specific anxiety-provoking situations. These feelings are usually accompanied by some physical symptoms such as alpitationsc,h est pain, or discomfort, difficulty breathing, and choking or smothering sensations. The presence of recurrent panic attacks, as well as apprehension about future attacks, is called Panic Disorder. Agoraphobia is a secondary disorder to Panic Disorder and characterised by anxiety about, or avoidance of, places in which panic may occur (Ollendick, 1998). These places/situations often include being outside the home alonbee, ing in a crowd, travelling in a bus, or being on a bridge. Other disorders that featureh eightened anxiety will bementioned in passing only. Obsessive-compulsive disorder (OCD) is characterised by obsessions (persistent thoughts, impulses, or images that are intrusive and distressing) and compulsions (repetitive behaviours, e.g. hand washing) (R. A. King, Leonard, & March, 1998).
Obsessions may centre on themes of personal contamination by germs, on harmb efalling loved ones,o n violent images, or on sexual or religious matters. Compulsions involving repeating, ordering, arranging, checking, watching rituals are common, Posttraumatic stress disorder (PTSD) is characterised by persistent re-experiencing of traumatic events accompanied by symptoms of arousal (Perrin, Smith, & Yule, 2000). People who have PTSD will take measures to avoid exposure to stimuli that they feel are associatedw ith the trauma. Acutest ress disorder is characterised by symptoms similar to those found in PTSD, but which occur immediately following the event. Selective mutism refers to a disorder in which the child has language but does not speak to unfamiliar people due to extremseh yness and social fear (Anstendig, 1999). Apart from thep resence of specific symptoms, criteria for all of the above disorders require that the problem causes significant interference with daily functioninagn, d that the symptomsh ave persisted for specified periods of time.

Childhood Anxiety in Ethnic Families: Current Status and Future Directions

Since 1947, Australia has undergone rapid demographic change, in both size and ethnic composition (Storer, 1985). Australia’s migration policies have resulted in one of the most ethnically diverse countries in the world. Current Australians were born in more than 20 countries, covering at least seven major religions, and even more ethnic groups (Storer, 1985). Despite this, little is understood about the psychological adjustment of Australia’s migrants. It is highly likely that the stress and change associated with migration causes significant anxiety in ethnic families. In addition to adjusting to a new culture, migrants are likely to be grieving the loss of family, friends, and traditional ways of life. These traditional values and beliefs typically undergo change as a result of being exposed to a Western society such as Australia.

For example, changes commonly occur in migrants’ attitudes toward marriage, sex roles, and child rearing (Storer, 1985). The result of these changes is a unique blend of new and traditional values being upheld in many migrant families. Understanding the experience of migrants and the associated cultural values and variables is important for developing an understanding of the experience of psychopathology in ethnic families. Although all mental health issues are influenced by cultural variables, this paper will only focus on the related constructs of anxiety and fear. The process of migration is likely to manifest as adjustment disorder for many migrant children. Clinically significant anxiety is also likely because of the difficult adjustments they are required to undergo. In addition, anxiety disorders are the most common form of psychopathology in children, with one in six Western children reporting anxiety difficulties (Chorpita, Albano, & Barlow, 1996; Dadds, Spence, Holland, Barrett, & Laurens, 1997; Mattison, 1992). These anxieties typically encompass such issues as fears about past, current, and future events; social worries; and separation anxieties. When the stressors of migration and cultural adjustment are added, it seems reasonable to assume that ethnic children in Australia will have an even greater prevalence of anxiety disorders than Australian-born children. Despite this, the majority of research contributing to our understanding of anxieties in children and adolescents derives largely from Anglo participants in Western countries and cultures (Australia, Britain, and the United States). Few studies have contributed to ourunderstanding of anxiety disorders in different populations and cultures. However, the culturally mediated beliefs, values, and traditions associated with socialisation practices play an important role in the kinds of issues that parents,teachers, and significant others perceive to be problematic. Consequently, there is a clear need to understand the impact of culture on the child and family. This need is intensified due to the inevitable fact that mental health services to culturally diverse children, youth, and families will be largely provided by practitioners who are not members of the cultural groups they are treating. If we are to meet the needs of our ethnically diverse society by developing and implementing culturally sensitive and appropriate services, it is vital that our understanding of psychopathology in ethnic families increases. The aims of this article are twofold. First, this article aims to review our current understanding of childhood anxiety disorders in ethnic families. Understanding the risk factors and clinical characteristics of anxiety in Australian migrant or ethnic families may help us to develop programs targeted to the particular needs of migrants. Research in Australia, whose colonisation history is brief, is limited. Consequently, international research with ethnic populations will be examined. Second, this article aims to provide readers with some guidelines for furthering our understanding of anxiety in ethnic children and their families. Australian researchers have an international reputation for their work in the area of childhood anxiety disorders. Yet our migrant and ethnic families have been largely ignored. If we are to adequately service the mental health needs of our ethnically diverse community, then researchers and clinicians must become more culturally aware in their work with ethnic families.

Early Intervention and Prevention of Anxiety Disorders in Children: Results at 2-Year Follow-Up

Anxiety problems are the most common form of psychological distress reported by children and adolescents (Garralda & Bailey,1986; Kashani, Orvaschel, Rosenberg, & Reid, 1989; Viken, 1985). However, increasing evidence points to the amenability of these problems to psychosocial intervention. Evaluations of Kendall’s (1994) program for 9- to 13-year-old children with overanxious, separation, and social anxiety showed that clinically significant gains can maintain over an average follow-up period of 3.5 years (Kendall & Southam-Gerow, 1996). A second outcome study has shown similar effects (Kendall et al., 1997). Barrett, Dadds, and Rapee (1996) compared a cognitive-behavioral intervention based on Kendall’s (1990) program with an intervention that also included a family intervention, again for a mixed group of overanxious, separation-anxious, and socially phobic 7- to 14- year-olds. Both interventions achieved a no-diagnosis status in over 60% of children at posttreatment compared with less than 30% of children on the wait list, and the effects were maintained at 12-month follow-up. Using controlled trials, both Barrett (in press) and Cobham, Dadds, and Spence (1998) have shown that similar success rates can be obtained by presenting the intervention in a cost-effective group format rather than in an individual format.

Inspired by these successes, the Queensland Early Intervention and Prevention of Anxiety Project (QEIPAP; Dadds, Spence,Holland, Barrett, & Laurens, 1997) aimed to evaluate the potential of these interventions to be used as preventive and early interventions. Thus, the project used a school-based screening procedure to identify, and then offer skills training to, high-risk children. The children ranged from those who were disorder free but showed mild anxious features to those who met criteria for an anxiety disorder but were in the less severe range. At pretreatment, approximately 75% of selected children who were interviewed met criteria for an anxiety diagnosis (mild to moderate severity). At postintervention, improvement was noted for both intervention and monitoring groups. Children who received the intervention emerged with lower rates of anxiety disorder at 6-month follow-up compared with those who were monitored only. Of those who had features of but no full disorder at pretreatment, 54% progressed to a diagnosable disorder at 6-month follow-up in the monitoring group compared with 16% in the intervention group. These results indicated that the intervention was successful in reducing rates of disorder in children with mild to moderate anxiety disorders, as well as preventing the onset of anxiety disorders in children with early features of a disorder.In this article, we report on the QEIPAP children at 12 and 24 months after the termination of the intervention. It was hypothesized that the intervention would be associated with lower rates of anxiety problems and disorders and higher ratings of improvementmade by parents and clinicians compared with the monitoring condition at these time points. A secondary aim was to examine child and family factors that were predictive of chronicity of anxiety problems. Specifically, we tested the findings of previous research that severity of initial problems, poor parental adjustment, and, more tentatively, female gender of the child are predictive of chronic anxiety problems (Barrett et al., 1996; Cobham et al., 1998).

Psychological Management of Anxiety Disorders in Childhood
Anxiety and fear are an inherent part of the human condition. In times of danger, they are transitory and adaptive. What is interpreted as dangerous, however, changes across the lifespan. As a consequence of children’s developmental experiences and their increasing cognitive abilities, the content of normative fears and anxieties generally shifts from concerns about concrete, external things to internalised, abstract anxieties (Koplewicz, 1996). Thus, infants tend to fear strangers, loud noises, and unexpected objects, while children fear separation from their parents, animals, loud noises, the dark, and the toilet. Between the ages of 4 and 6, predominant fears include kidnappers, robbers, ghosts, and monsters. At 6 years, fears of bodily injury, death, and failure develop. These may continue into early adolescence. At 10 or 11 years of age, fears regarding social comparison, physical appearance, personal conduct and school examinations may predominate. However, anxiety can be an unpleasant feeling that arises without any obvious threat. It consists of a mixture of physiological symptoms (e.g. sweaty palms,“butterflies” in the stomach), behavioural signs (e.g. avoidance), and cognitive components (e.g. “I’m going to fail and everyone will laugh at me”). Children and adolescents who have anxiety problems experience some combination of the following: unrealistic and excessive worry about past or future events and about performance; need for reassurance; marked self-consciousness; somatic complaints with no physical cause; restlessness or feeling “keyed up” or “on edge”; fatigue; difficulty concentrating; irritability; distress on separation from parents; school refusal; panic attacks; avoidance of situations; distress in social situations; phobias; obsessions or compulsions. Recently, research ashown that many anxiety problems begin in childhood and thtahte se are a common form of psychological problem and can be highly distressing and associated with a range osfo cial impairments (Dadds, Barrett, & Cobham, 1997). Thus, skills forbassessing and treating childhooadn xiety problems should be in the repertoire of all child mental health specialists. This paper presents an overview of these skills.

Types of Anxiety Disorders in Childhood

Categorical systems for classifying anxiety disorders are useful but not without problems. The individual categories have enormous overlap in specific symptoms, and even after controlling for this overlap, the majofr ity sufferers will show more than one category. Also, experiences of anxiety fall on a continuum of severity and the assignment of a disorder necessitates drawing an arbitrary cutoff on this continuum. At this point, theries precious littled ata tos how that thed ifferent child anxiety disorders are associated with different etiological, prognostic, and treatment factors.
Notwithstanding, use of a diagnostic system can greatly aid clinical precision and research progress. The main categories of anxiety disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) are described below.

Separation anxiety disorder (SAD) is one of the most common anxiety problems found in children and is developmentally inappropriate and excessive anxiety regarding separation from attachmentf igures in a child’s life (Silove, Manicavasagar, Curtis, & Blaszczynski, 1996). Generalised anxiety disorder (GAD) is exaggerated or uncontrollable anxiety, physiological arousal, and/or worry about events (Masi, Mucci, Favilla, Romano, & Poli, 1999). It is characterised by selfconsciousness, sleep disturbance, excessive reassurance seeking, and worry about future (e.g. going to see a doctor) or past events (e.g. something the person said), and anxiety about performance and competence. Specific phobias (SP) are characterised by marked fear of a specific feared object or situation that is not a realistic threat (N. J. King, Hamilton, & Ollendick, 1998). Social phobia (SocP) is characterised by fear of embarrassment and anxiety when exposed to social or performance situations (e.g. going to parties, speaking in front of a group). Children with social phobia avoid feared situations or, if necessary, endure them with intense anxiety.

Panic attacks are discrete periods in which there is a sudden onset of intense apprehension, fearfulness, or terror, often associated withfe elings of impending doom, that occur outside of specific anxiety-provoking situations. These feelings are usually accompanied by some physical symptoms such as palpitationsc,h est pain, or discomfort, difficulty breathing, and choking or smothering sensations. The presence of recurrent panic attacks, as well as apprehension about future attacks, is called Panic Disorder. Agoraphobia is a secondary disorder to Panic Disorder and characterised by anxiety about, or avoidance of, places in which panic may occur (Ollendick, 1998). These places/situations often include being outside the home alonbee, ing in a crowd, travelling in a bus, or being on a bridge. Other disorders that featureh eightened anxiety will be mentioned in passing only. Obsessive-compulsive disorder (OCD) is characterised by obsessions (persistent thoughts, impulses, or images that are intrusive and distressing) and compulsions (repetitive behaviours, e.g. hand washing) (R. A. King, Leonard, & March, 1998). Obsessions may centre on themes of personal contamination by germs, on harmb efalling loved ones,o n violent images, or on sexual or religious matters. Compulsions involving repeating, ordering, arranging, checking, watching rituals are common, Posttraumatic stress disorder (PTSD) is characterised by persistent re-experiencing
of traumatic events accompanied by symptoms of arousal (Perrin, Smith, & Yule, 2000). People who have PTSD will take measures to avoid exposure to stimuli that they feel are associatedw ith the trauma. Acutest ress disorder is characterised by symptoms similar to those found in PTSD, but which occur immediately following the event. Selective mutism refers to a disorder in which the child has language but does not speak to unfamiliar people due to extremseh yness and social fear (Anstendig, 1999)