Tessa Reardon

Background: Childhood anxiety disorders are common and lead to substantial negative long-term outcomes in various life domains. Although digital interventions for preventing childhood anxiety problems have been increasingly used in the recent decade, there is limited evidence documenting their cost-effectiveness (CE). Objective: This study aimed to evaluate the CE of a parent-led online cognitive behavioral therapy with therapist support (OSI+TS) alongside usual school practice (USP), compared to USP alone for children aged 4‐7 years at risk of anxiety disorders identified through universal school screening. Methods: The economic evaluation was conducted alongside the MYCATS trial (N=865), a parallel group, superiority cluster randomized trial across 95 primary or infant schools in England. Schools were randomized (1:1) to OSI+TS or USP, stratified by school-level deprivation. The primary analyses, at 12 months after randomization, considered child quality-adjusted life years (QALYs) as the health economic outcome, using both the UK adult and the Australia adolescent value sets, and costs were from the National Health Service and Personal Social Services perspective. Incremental cost-effectiveness ratios (ICERs) were compared to the UK National Institute for Health and Care Excellence (NICE) recommended threshold of £20,000-£30,000 (£1=US $1.35 as of September 10, 2026) per QALY gained, as per predefined Health Economics Analysis Plan. Sensitivity analyses included a societal perspective and the application of the new NICE cost-effectiveness threshold. Results: Children receiving OSI+TS gained 0.021 (95% CI 0.010-0.033; P <.001) and 0.043 (95% CI 0.021-0.064; P <.001) QALYs, respectively, for United Kingdom and Australia value sets, with an additional cost of £244.16 compared to school usual practice only, resulting in ICERs of £11,462.47 and £5,700.98, respectively. At the £20,000 threshold, OSI+TS had an 88.2% or 99.3% chance of being cost-effective. Conclusions: OSI+TS is cost-effective compared to usual school provision, supporting its future implementation for children at risk of anxiety problems.

Mental health problems, including emotional problems, are linked to adverse educational outcomes among children and adolescents. This study examines the association between early onset of mental health problems generally, and emotional problems specifically, at ages 5-14, and outcomes from the General Certificate of Secondary Education (GCSE), a secondary education qualification, at age 16 for 4,783 students in England, using the Millennium Cohort Study dataset linked to the National Pupil Database. We found that the onset of mental health problems at ages 5, 7, 11 and 14 had a significant and negative association with all GCSE outcomes. We also found negative associations between early onset emotional problems and GCSE outcomes, although results were most stark for emotional problems that onset at age 11, with statistically significant negative associations with all GCSE outcomes. School absence was identified as a potential mediator of the negative association. Furthermore, this study found that the potential loss of productivity related to mental health problems in general and emotional problems in particular was over £23,000 and £11,000 per affected individual, respectively, which could translate into approximately £2.57 billion and £1.6 billion, respectively at the population level for England. These findings highlight the importance of early intervention for children and adolescents with mental health problems to improve educational and future outcomes.

Background: Providing accessible CBT for young children identified as at risk for anxiety disorders through screening in schools could reduce later problems. This study aimed to evaluate the effectiveness of parent‐led CBT delivered via online and telephone call support alongside usual school provision, compared to usual school provision only for young children identified through screening as having at least one risk. Methods: We conducted a pragmatic, parallel group, superiority cluster randomised controlled trial in 95 primary/infant schools in England. Parents of children (aged 4–7) in sampled classes completed screening, and children who screened positive for one or more risks (anxiety symptoms/inhibition/parent anxiety) were eligible for the trial. Schools (clusters) were randomised (1:1) to intervention or usual school practice, stratified by school‐level deprivation. Schools in both arms continued with usual provision, and parents in intervention schools were offered parent‐led CBT via online and telephone support. The primary outcome was the presence of an anxiety disorder diagnosis at 12 months, assessed via the ADIS‐P administered by independent assessors. Secondary clinical outcomes included parent‐reported child anxiety symptoms, related interference, externalising symptoms, additional risks and intervention targets at 12 weeks and 12 months. Primary analyses were conducted on the full intention‐to‐treat population. The trial was prospectively registered with ISRCTN 82398107. Results: In total, 2,328 children were screened; 1,172 were eligible; 865 enrolled. Forty‐eight schools (434 children) were assigned to intervention and 47 schools (431 children) to usual school practice. At 12 months, the overall frequency of anxiety disorders was low, 6.8% (21/310) of children in the intervention arm compared to 11.5% (36/312) in the usual school practice arm; this difference was not statistically significant (adjusted odds ratio 0.67 [0.37 to 1.21], p = .19). However, the intervention was superior to usual school practice across all secondary outcomes (standardised mean difference: 0.15 to 0.47 at 12 weeks; 0.19 to 0.41 at 12 months). No serious adverse events were reported. Conclusions: Although the intervention did not significantly reduce anxiety disorders at 12 months, improvements across all other assessed outcomes indicate this approach brings wider immediate benefits and reduces known risks for future anxiety disorders. Future research needs to consider longer‐term preventative effects.

The Preschool Anxiety Scale (PAS) is a parent-report scale measuring young children's anxiety symptoms involving five specific anxiety symptoms (separation anxiety, physical injury fears, social phobia, obsessive-compulsive disorder, generalized anxiety) that load on a higher-order factor representing general anxiety shared by all specific anxiety symptom subtypes. Although the PAS has been widely used to assess anxiety symptoms in young children, few studies have tested its measurement invariance for group comparisons. Using data from a sample of 2,221 children and their parents/carers in the United Kingdom, this study investigated the measurement invariance of the higher-order model of the PAS across child age (4-6 years vs. 6-7 years), gender (girls vs. boys), parental anxiety (low vs. high level), and children's living circumstances (before vs. after the removal of COVID-19 restrictions). Our findings demonstrated the good factor structure, internal consistency, and convergent validity of the higher-order model of the PAS in all subgroups and supported its configural, metric, and scalar invariance across these subgroups. Therefore, the findings suggest that the PAS is a reliable and valid instrument for assessing specific anxiety symptoms and general anxiety among young children in the United Kingdom and that comparisons can be made between the subgroups under examination. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Difficulties identifying anxiety disorders in primary‐school aged children present significant barriers to timely access to support and intervention. This study aimed to develop a brief assessment tool that can identify children with anxiety disorders in community settings, with a high level of sensitivity and specificity.Methods: Children (aged 8–11 years), and their parents/carers and teachers from 19 primary/junior schools in England each completed a pool of questionnaire items that assessed child anxiety symptoms and associated impact. Diagnostic assessments (Anxiety Disorder Interview Schedule for Children: Child and Parent interviews) were administered by independent assessors to determine the presence/absence of anxiety disorders in children. We created alternative candidate brief child‐, parent‐, teacher‐report questionnaires consisting of the ‘best’ items selected from the wider pool of completed items. We used exploratory factor analysis to reduce the item pool, and multivariable backward elimination logistic regression to identify items that were the strongest predictors of the presence/absence of an anxiety disorder.Results: Parents/carers of 646 children provided consent; child/parent/teacher‐report questionnaires were collected for 582/646/565 children respectively; and diagnostic outcome data were collected for 463 children. None of the brief child‐ nor teacher‐report questionnaires achieved acceptable sensitivity/specificity (<75%). Parent‐report questionnaires including between 2 and 9 items that assess anxiety symptoms and/or associated impact achieved acceptable sensitivity and specificity (≥75%).Conclusions: The two‐item parent‐report measure that assesses distress and impairment associated with anxiety brings the advantage of brevity and has the potential to be used in community settings to improve identification of children with anxiety disorders.

Anxiety problems are common in children and can have profound adverse effects on personal, social and academic life. Almost 40% of anxiety disorders emerge before age 14, making primary schools invaluable settings for prevention and early support of child anxiety. Research indicates that school‐based interventions can be costly and difficult to schedule, school staff lack confidence to deliver them effectively, and outcomes are mixed. One solution may be for school staff to adapt and enhance their day‐to‐day practices to better support children with anxiety. This systematic review aims to summarise what is known about the relationship between teachers' classroom management and anxiety in primary school‐aged children. We searched ASSIA, British Education Index, Education Abstracts, Embase, ERIC, MEDLINE, PsycINFO and Scopus in December 2020 and June 2022, using a predefined strategy. We included studies of any design, published in peer‐reviewed journals at any time, in any language, reporting associations between day‐to‐day classroom management strategies/methods and anxiety/internalising outcomes in children aged 4–11 years, taught in mainstream primary schools. Studies were assessed for quality/risk of bias. We identified eight studies (six quantitative, two qualitative) including 4505 children. We found some evidence that authoritarian, controlling and punitive classrooms may be linked to higher levels of anxiety, although, overall, existing evidence indicates either a weak or no association between classroom management and anxiety. This review highlights a paucity of research in this area. Furthermore, variability in design, measures and quality makes drawing firm conclusions difficult. Recommendations for future research are discussed. Context and Implications: Rationale for this study: This review explores what is currently known about the relationship between teachers' day‐to‐day classroom management practices and anxiety in primary school‐aged children. Why the findings matter: Anxiety problems are common and often start in the primary years, however there is scant evidence to inform primary school educators on how day‐to‐day classroom practices can be used to better support children with or at risk of anxiety problems. Implications for researchers and practitioners: This review is relevant for primary classroom practitioners, school leaders, education professionals, academics, researchers and policymakers keen to better understand how to support those with or at risk of anxiety. Although overall findings indicate very small associations between teaching styles/practices and anxiety in children, there is very little research to draw on. Research is urgently needed that uses robust designs to focus on whether specific, feasible, day‐to‐day strategies can be used by school staff to effectively manage and minimise children's anxiety problems and, if so, how school staff can best be supported and equipped to deliver them.

Background: Anxiety problems are extremely common and have an early age of onset. We previously found, in a study in England, that fewer than 3% of children with an anxiety disorder identified in the community had accessed an evidence‐based treatment (Cognitive Behavioural Therapy; CBT). Key ways to increase access to CBT for primary school‐aged children with anxiety problems include (a) proactive identification through screening in schools, (b) supporting parents and (c) the provision of brief, accessible interventions (and capitalising on technology to do this). Method: We provided a brief, therapist guided treatment called Online Support and Intervention (OSI) to parents/carers of children identified, through school‐based screening, as likely to have anxiety problems. Fifty out of 131 children from 17 Year 4 classes in schools in England screened positive for ‘possible anxiety problems’ and 42 (84%) of these (and 7 who did not) took up the offer of OSI. We applied quantitative and qualitative approaches to assess children's outcomes and families' experiences of this approach. Results: Inbuilt outcome monitoring indicated session on session improvements throughout the course of treatment, with substantial changes across measures by the final module (e.g. Child Outcome Rating Scale d = 0.84; Goal Based Outcomes d = 1.52). Parent engagement and satisfaction was high as indicated by quantitative and qualitative assessments, and intervention usage. Conclusions: We provide promising preliminary evidence for the use of OSI as an early intervention for children identified as having anxiety problems through school‐based screening.

Background: Systematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for (1) children (aged 8–9) who screen positive for anxiety problems at baseline (target population) and (2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice (‘screening and intervention’), compared to assessment and usual school practice only (‘usual school practice’). Methods: The trial design is a parallel-group, superiority cluster randomised controlled trial, with schools (clusters) randomised to ‘screening and intervention’ or ‘usual school practice’ arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to ‘screening and intervention’: (1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child’s screening outcomes (after randomisation), (2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention and (3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent- and teacher-report measures for the target population and total population at baseline (before randomisation), 4 months, 12 months and 24 months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12 months post-randomisation.Discussion: This trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families and delivering a brief parent-led online intervention through schools is effective and cost-effective.Trial registration: ISRCTN registry ISRCTN76119074. Prospectively registered on 4.1.2022.

BackgroundSystematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for: 1) children (aged 8-9) who screen positive for anxiety problems at baseline (target population), and 2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice (‘screening and intervention’), compared to assessment and usual school practice only (‘usual school practice’).MethodsThe trial design is a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to ‘screening and intervention’ or ‘usual school practice’ arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to ‘screening and intervention’: 1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child’s screening outcomes (after randomisation), 2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention, and 3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent-, and teacher-report measures for the target population and total population at baseline (before randomisation), 4-months, 12-months and 24-months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12-months post-randomisation.DiscussionThis trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families, and delivering a brief parent-led online intervention through schools is effective and cost-effective.Trial registration:ISRCTN registry: ISRCTN76119074. Prospectively registered on 4.1.2022 https://www.isrctn.com/ISRCTN76119074