Streamlined Prevention and Early Intervention for Pediatric Anxiety Disorders: A Randomized Controlled Trial

  • Armando A. PinaEmail author
  • Nancy A. Gonzales
  • Gina L. Mazza
  • Heather J. Gunn
  • Lindsay E. Holly
  • Ryan D. Stoll
  • Julia Parker
  • Amanda Chiapa
  • Henry Wynne
  • Jenn-Yun Tein


There is a need to optimize the fit between psychosocial interventions with known efficacy and the demands of real-word service delivery settings. However, adaptation of evidence-based interventions (EBI) raises questions about whether effectiveness can be retained. This randomized controlled trial (RCT) evaluated a streamlined package of cognitive, behavior, and social skills training strategies known to prevent and reduce anxiety symptom and disorder escalation in youth. A total of 109 youth (Mage = 9.72; 68% girls; 54% Latinx) at risk based on high anxiety were randomized to the streamlined prevention and early intervention (SPEI) (n = 59) or control (n = 50) and were assessed at pretest, posttest, and 12-month follow-up. A main objective was to determine whether our redesign could be delivered by community providers, with acceptable levels of fidelity, quality, and impact. In terms of process evaluation results, there was high protocol fidelity, excellent clinical process skills, few protocol adaptations, and high satisfaction with the SPEI. In terms of outcomes, there were no significant main or moderated effects of the SPEI at the immediate posttest. However, at the follow-up, youth in the SPEI reported greater self-efficacy for managing anxiety-provoking situations, greater social skills, and fewer negative cognitive errors relative to controls. Collectively, findings suggest that the redesigned SPEI might be an attractive and efficient solution for service delivery settings.


Prevention Anxiety Children Latinx Hybrid-1 effectiveness 


Funding Information

This work was supported in part by grant number K01MH086687 awarded to A. Pina from the National Institute of Mental Health.

Compliance with Ethical Standards

The content is solely the responsibility of the authors and does not represent the official views of the funding agency. All study procedures and measures were reviewed and approved by the Institutional Review Board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA, US: Sage Publications, Inc. Scholar
  2. Allen, K. B., Allen, B., Austin, K. E., Waldron, J. C., & Ollendick, T. H. (2015). Synchrony–desynchrony in the tripartite model of fear: Predicting treatment outcome in clinically phobic children. Behaviour Research and Therapy, 71, 54–64. Scholar
  3. Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55, 1247–1263. Scholar
  4. Barrett, P., & Turner, C. (2001). Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40, 399–410.Google Scholar
  5. Beidel, D. C., Turner, S. M., & Morris, T. L. (2004). Social effectiveness therapy for children and adolescents (SET-C). Ontario, Toronto: Multi-Health Systems, Inc.Google Scholar
  6. Breitenstein, S. M., Gross, D., Garvey, C. A., Hill, C., Fogg, L., & Resnick, B. (2010). Implementation fidelity in community-based interventions. Research in Nursing & Health, 33, 164–173. Scholar
  7. Calear, A. L., Christensen, H., Mackinnon, A., Griffiths, K. M., & O'Kearney, R. (2009). The YouthMood Project: A cluster randomized controlled trial of an online cognitive behavioral program with adolescents. Journal of Consulting and Clinical Psychology, 77, 1021–1032. Scholar
  8. Calear, A. L., Batterham, P. J., Poyser, C. T., Mackinnon, A. J., Griffiths, K. M., & Christensen, H. (2016). Cluster randomised controlled trial of the e-couch Anxiety and Worry program in schools. Journal of Affective Disorders, 196, 210–217. Scholar
  9. Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, 275–282. Scholar
  10. Chavira, D. A., Bustos, C., Garcia, M., Reinosa Segovia, F., Baig, A., Ng, B., & Camacho, A. (2018). Telephone-assisted, parent-mediated CBT for rural Latino youth with anxiety: A feasibility trial. Cultural Diversity and Ethnic Minority Psychology, 24, 429–441. Scholar
  11. Chiu, A. W., Langer, D. A., McLeod, B. D., Har, K., Drahota, A., Galla, B. M., et al. (2013). Effectiveness of modular CBT for child anxiety in elementary schools. School Psychology Quarterly, 28, 141–153. Scholar
  12. Chorpita, B. F., Daleiden, E. L., & Weisz, J. R. (2005). Identifying and selecting the common elements of evidence-based interventions: A distillation and matching model. Mental Health Services Research, 7, 5–20. Scholar
  13. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates.Google Scholar
  14. Cook, R. D. (1977). Detection of influential observation in linear regression. Technometrics, 19, 15–18. Scholar
  15. Crist, J. J. (2004). What to do when you’re scared & worried: A guide for kids. Minneapolis: Free Spirit Publishing.Google Scholar
  16. Cunningham, N. R., & Ollendick, T. H. (2010). Comorbidity of anxiety and conduct problems in children: Implications for clinical research and practice. Clinical Child and Family Psychology Review, 13, 333–347. Scholar
  17. Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50, 217–226. Scholar
  18. De Los Reyes, A., Alfano, C. A., & Beidel, D. C. (2010). The relations among measurements of informant discrepancies within a multisite trial of treatments for childhood social phobia. Journal of Abnormal Child Psychology, 38, 395–404. Scholar
  19. De Los Reyes, A., Bunnell, B. E., & Beidel, D. C. (2013). Informant discrepancies in adult social anxiety disorder assessments: Links with contextual variations in observed behavior. Journal of Abnormal Psychology, 122, 376–386. Scholar
  20. Fagan, A. A., Hanson, K., Briney, J. S., & Hawkins, J. D. (2012). Sustaining the utilization and high quality implementation of tested and effective prevention programs using the Communities That Care prevention system. American Journal of Community Psychology, 49, 365–377. Scholar
  21. Forman, S. G., Olin, S. S., Hoagwood, K. E., Crowe, M., & Saka, N. (2009). Evidence-based interventions in schools: Developers’ views of implementation barriers and facilitators. School Mental Health, 1, 26–36. Scholar
  22. Fox, J. S. (2006). Get organized without losing it. Minneapolis: Free Spirit Publishing.Google Scholar
  23. Gresham, F. M., & Elliott, S. N. (2008). Social Skills Improvement System Rating Scales. Minneapolis, NCS Pearson.Google Scholar
  24. Heyne, D., King, N., Tonge, B., Rollings, S., Pritchard, M., Young, D., & Myerson, N. (1998). The self-efficacy questionnaire for school situations: Development and psychometric evaluation. Behaviour Change, 15, 31–40. Scholar
  25. Holly, L. E., Little, M., Pina, A. A., & Caterino, L. C. (2015). Assessment of anxiety symptoms in school children: A cross-sex and ethnic examination. Journal of Abnormal Child Psychology, 43, 297–309.Google Scholar
  26. Individuals with Disabilities Education Improvement Act 20 (2004) U.S.C. § 1400Google Scholar
  27. Ingul, J. M., Klöckner, C. A., Silverman, W. K., & Nordahl, H. M. (2012). Adolescent school absenteeism: Modeling social and individual risk factors. Child and Adolescent Mental Health, 17, 93–100. Scholar
  28. Jurs, S. G., & Glass, G. V. (1971). The effect of experimental mortality on the internal and external validity of the randomized comparative experiment. The Journal of Experimental Education, 40, 62–66. Scholar
  29. Kapp, K. M. (2012). The gamification of learning and instruction: Game-based methods and strategies for training and education. New Jersey: John Wiley & Sons.Google Scholar
  30. Kendall, P. C., Cummings, C. M., Villabø, M. A., Narayanan, M. K., Treadwell, K., Birmaher, B., & Gosch, E. (2016). Mediators of change in the Child/Adolescent Anxiety Multimodal Treatment Study. Journal of Consulting and Clinical Psychology, 84, 1–14. Scholar
  31. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21, 169–184. Scholar
  32. Kilian, R., Losert, C., Park, A. L., McDaid, D., & Knapp, M. (2010). Cost-effectiveness analysis in child and adolescent mental health problems: An updated review of literature. International Journal of Mental Health Promotion, 12, 45–57. Scholar
  33. Kohn, R. (2014). Trends, gaps, and disparities in mental health. In S. O. Okpaku (Ed.), Essentials of global mental health (pp. 27–38). New York: Cambridge University Press. Scholar
  34. Lang, P. J. (1968). Fear reduction and fear behavior: Problems in treating a construct. In Research in Psychotherapy Conference, 3rd, 1966, Chicago, US. American Psychological AssociationGoogle Scholar
  35. Langley, A. K., Nadeem, E., Kataoka, S. H., Stein, B. D., & Jaycox, L. H. (2010). Evidence-based mental health programs in schools: Barriers and facilitators of successful implementation. School Mental Health, 2, 105–113. Scholar
  36. Laurent, J., Catanzaro, S. J., & Joiner Jr., T. E. (2004). Development and preliminary validation of the physiological hyperarousal scale for children. Psychological Assessment, 16, 373–380. Scholar
  37. Leitenberg, H., Yost, L. W., & Carroll-Wilson, M. (1986). Negative cognitive errors in children: Questionnaire development, normative data, and comparisons between children with and without self-reported symptoms of depression, low self-esteem, and evaluation anxiety. Journal of Consulting and Clinical Psychology, 54, 528–536. Scholar
  38. Lewinsohn, P. M., Gotlib, I. H., Lewinsohn, M., Seeley, J. R., & Allen, N. B. (1998). Gender differences in anxiety disorders and anxiety symptoms in adolescents. Journal of Abnormal Psychology, 107, 109–117. Scholar
  39. Lipsey, M. W. (1990). Theory as method: Small theories of treatments. In L. Sechrest, E. Perrin, & J. Bunker (Eds.), Research methodology: Strengthening causal interpretations of nonexperimental data (DHHS Publication No. 90-3454, pp. 33–51). Washington, DC: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research.Google Scholar
  40. MacKinnon, D. P. (2011). Integrating mediators and moderators in research design. Research on Social Work Practice, 21, 675–681. Scholar
  41. March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 554–565. Scholar
  42. Maric, M., Heyne, D. A., MacKinnon, D. P., Van Widenfelt, B. M., & Westenberg, P. M. (2012). Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal. Behavioural and Cognitive Psychotherapy, 41, 549–564. Scholar
  43. McLeod, B. D., Southam-Gerow, M. A., Tully, C. B., Rodriguez, A., & Smith, M. M. (2013). Making a case for treatment integrity as a psychosocial treatment quality indicator for youth mental health care. Clinical Psychology: Science and Practice, 20, 14–32. Scholar
  44. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980–989. Scholar
  45. Muthén, L. K., & Muthén, B. O. (1998-2014). Mplus user’s guide. Seventh Edition.Google Scholar
  46. National Academies of Sciences, Engineering, and Medicine. (2017). Advancing the science to improve population health: Proceedings of a workshop. Washington, D.C: National Academies Press.Google Scholar
  47. Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., & Waters, A. (2004). A parent-report measure of children’s anxiety: Psychometric properties and comparison with child-report in a clinic and normal sample. Behaviour Research and Therapy, 42, 813–839. Scholar
  48. Ost, L. G., Svensson, L., Hellstrom, K., & Lindwall, R. (2001). One-session treatment of specific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69(5), 814–824. Scholar
  49. Öst, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134–145.Google Scholar
  50. Pina, A. A., Silverman, W. K., Fuentes, R. M., Kurtines, W. M., & Weems, C. F. (2003). Exposure-based cognitive-behavioral treatment for phobic and anxiety disorders: Treatment effects and maintenance for Hispanic/Latino relative to European-American youths. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 1179–1187. Scholar
  51. Pina, A., Holly, L. E., Wynne, H., Zerr, A. A., & Stoll, R. (2012a). A social network and qualitative data approach to assist transportability of a child anxiety prevention program into elementary school settings. Paper presented at the meeting of the Society for Prevention Research, Washington, DC.Google Scholar
  52. Pina, A. A., Zerr, A. A., Villalta, I. K., & Gonzales, N. A. (2012b). Indicated prevention and early intervention for childhood anxiety: A randomized trial with Caucasian and Hispanic/Latino youth. Journal of Consulting and Clinical Psychology, 80, 940–946. Scholar
  53. Pretti-Frontczak, K., & Bricker, D. (2004). An activity-based approach to early intervention. Brookes Publishing Company. Baltimore, MD 21285.Google Scholar
  54. Rapee, R. M., Wignall, A., Sheffield, J., Kowalenko, N., Davis, A., McLoone, J., & Spence, S. H. (2006). Adolescents’ reactions to universal and indicated prevention programs for depression: Perceived stigma and consumer satisfaction. Prevention Science, 7, 167–177. Scholar
  55. Rogers, E. M. (2003). Diffusion of innovations theory (5th ed.). Free Press: New York. Scholar
  56. Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2015). Effectiveness trial of an indicated cognitive–behavioral group adolescent depression prevention program versus bibliotherapy and brochure control at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 83, 736–747. Scholar
  57. Romain, T. (1997). How to do homework without throwing up. Minneapolis, MN: Free Spirit Publishing.Google Scholar
  58. Rotheram-Borus, M. J., Swendeman, D., & Chorpita, B. F. (2012). Disruptive innovations for designing and diffusing evidence-based interventions. American Psychologist, 67, 463–476. Scholar
  59. Rothman, K. J., Greenland, S., & Walker, A. M. (1980). Concepts of interaction. American Journal of Epidemiology, 112, 467–470. Scholar
  60. Scholten, H., Malmberg, M., Lobel, A., Engels, R. C., & Granic, I. (2016). A randomized controlled trial to test the effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PLOS One, 11, e0147763. Scholar
  61. Schoneveld, E. A., Malmberg, M., Lichtwarck-Aschoff, A., Verheijen, G. P., Engels, R. C., & Granic, I. (2016). A neurofeedback video game (MindLight) to prevent anxiety in children: A randomized controlled trial. Computers in Human Behavior, 63, 321–333. Scholar
  62. Silverman, W. K., & Albano, A. M. (1996). Anxiety disorders interview schedule for DSM-IV: Child interview schedule. Graywind Publications.Google Scholar
  63. Silverman, W. K., & Kurtines, W. M. (1996). Anxiety and phobic disorders: A pragmatic approach. New York, NY, US: Plenum Press. Scholar
  64. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 37, 105–130. Scholar
  65. Silverman, W. K., Kurtines, W. M., Jaccard, J., & Pina, A. A. (2009). Directionality of change in youth anxiety treatment involving parents: An initial examination. Journal of Consulting and Clinical Psychology, 77, 474–485. Scholar
  66. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545–566. Scholar
  67. Spoth, R., Trudeau, L., Redmond, C., & Shin, C. (2014). Replication RCT of early universal prevention effects on young adult substance misuse. Journal of Consulting and Clinical Psychology, 82, 949–963. Scholar
  68. Stockings, E. A., Degenhardt, L., Dobbins, T., Lee, Y. Y., Erskine, H. E., Whiteford, H. A., & Patton, G. (2016). Preventing depression and anxiety in young people: A review of the joint efficacy of universal, selective and indicated prevention. Psychological Medicine, 46, 11–26. Scholar
  69. Sulkowski, M. L., Joyce, D. K., & Storch, E. A. (2012). Treating childhood anxiety in schools: Service delivery in a response to intervention paradigm. Journal of Child and Family Studies, 21, 938–947. Scholar
  70. Taylor, J. H., Lebowitz, E. R., Jakubovski, E., Coughlin, C. G., Silverman, W. K., & Bloch, M. H. (2018). Monotherapy insufficient in severe anxiety? Predictors and moderators in the Child/Adolescent Anxiety Multimodal Study. Journal of Clinical Child & Adolescent Psychology, 47, 266–281. Scholar
  71. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 2753–2766. Scholar
  72. Weems, C. F., Scott, B. G., Graham, R. A., Banks, D. M., Russell, J. D., Taylor, L. K., et al. (2015). Fitting anxious emotion-focused intervention into the ecology of schools: Results from a test anxiety program evaluation. Prevention Science, 16, 200–210. Scholar
  73. West, S. G., & Aiken, L. S. (1997). Toward understanding individual effects in multicomponent prevention programs: Design and analysis strategies. In K. J. Bryant, M. Windle, & S. G. West (Eds.), The science of prevention: Methodological advances from alcohol and substance abuse research (pp. 167–209). Washington, DC, US: American Psychological Association.CrossRefGoogle Scholar
  74. Yuan, K. H., & Bentler, P. M. (2000). Three likelihood-based methods for mean and covariance structure analysis with nonnormal missing data. Sociological Methodology, 30, 165–200. Scholar

Copyright information

© Society for Prevention Research 2020

Authors and Affiliations

  1. 1.Department of PsychologyArizona State UniversityTempeUSA
  2. 2.Department of PsychologyMarquette UniversityMilwaukeeUSA

Personalised recommendations