The art is in the delivery

Anxiety is a common symptom and a common disorder among children. Anxiety may persist through adolescence and into adulthood, negatively impacting both mental and physical health over the lifespan. Early intervention directed to children at risk of anxiety and their parents has the potential to modify these trajectories and to improve function. A team from La Trobe, Deakin, Melbourne and Macquarie Universities and the Murdoch Children’s Research Institute report translational research in which an intervention (Cool Little Kids) was delivered to parents of inhibited children identified in a population sample of school entrants, with the aim of preventing or reducing childhood anxiety (Bayer et al., 2018). This six-session programme was based on cognitive behavioural therapy techniques and targeted inhibited children because they are known to have an elevated risk of developing anxiety disorder. The rationale is further supported by the outcomes of previous efficacy trials conducted in parents of children referred to university psychology clinics (Kennedy et al., 2009). The methodology of the trial was robust. If children screened positively for high behavioural inhibition, their parents were randomised to intervention or control arms which appeared well matched and broadly representative of the population. Sources of potential attrition bias were transparent. The authors’ interpretation of the data was conservative and appropriate.

While there were modest benefits on two secondary outcome measures in the active versus control condition that assess internalising symptoms, the study was unable to demonstrate the impact on rates of anxiety disorder achieved in their previous smaller samples (Kennedy et al., 2009; Rapee et al., 2005). Parents in this study were less adherent to the prevention programme compared with parents recruited to university clinics. The authors concluded that across a population of inhibited pre-schoolers, the preventive intervention does not impact on anxiety disorder after 1 year. Why should this be so?

The authors experienced difficulty in keeping parents in the programme even though this intervention was delivered for free, in a known and trusted location and at convenient times. One-third of parents randomised to the active condition attended five or more sessions, meaning that only a minority were exposed to the intervention as intended. Educating parents about the known longer term risks of the inhibited temperament and childhood anxiety may increase parental motivation to seek change, a strategy that has been successfully utilised in the Family Check-Up model for early child behavioural problems. Alternative delivery platforms, such as the Internet, may be more ‘user-friendly’ for parents. Bayer and colleagues have considered this already and have demonstrated the efficacy of Internet-delivered Cool Little Kids for 3- to 6-year olds with inhibited temperament (Morgan et al., 2017).

Inhibited temperament is of course only one risk factor for anxiety, and any study of this nature could be confounded by other factors that are inducing anxiety in the children. Other known targets include parent mental illness and violence exposure, neither of which would have been modified by the Cool Little Kids programme.

Might this problem be better addressed by universal rather than targeted intervention? For problems that are distributed continuously across the population (e.g. hypertension), universal interventions that lower the mean value of the index variable for the whole population may be more helpful than targeted interventions. Data from a systematic review suggest this may be true for childhood anxiety. Neil and Christensen (2009) found that universal programmes to reduce childhood anxiety were associated with a higher proportion of significant trials and larger effect sizes compared with indicated and selective programmes. In addition, a more recent well-conducted trial of a universal intervention to prevent or reduce anxiety in 9- and 10-year olds in the United Kingdom (Stallard et al., 2014) found a small but robust difference between the active and control groups for children with low anxiety. That said, Neil and Christensen (2009) reported that indicated programmes achieved a higher proportion of positive outcomes and stronger effects at longer term follow-up. It is feasible, therefore, that benefits of intervention may be found when the Melbourne cohort is re-evaluated at 24 months.

Interventions such as Cool Little Kids are clearly effective in reducing childhood anxiety in some contexts, but the art is in the delivery. The challenge is finding ways to increase uptake and make the interventions more acceptable to target populations.

See Research by Bayer et al. 52: 181–191.