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Intervention Summary

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Cool Kids Child and Adolescent Anxiety Management Program

The Cool Kids Child and Adolescent Anxiety Management Program (Cool Kids) treats anxiety disorders in children and adolescents ages 6-18 years. With a focus on teaching anxiety management skills, the manualized program includes sessions on identifying anxious thoughts, feelings, and behaviors (psychoeducation); challenging anxious thoughts (cognitive restructuring); approaching avoided situations/events (exposure); and using additional coping skills such as systematic problem solving, social skills, assertiveness skills, and effective strategies for dealing with teasing and bullying (coping skills). Cool Kids also helps the parent or other primary caretaker to support the child in the use of these new skills and to practice strategies for parenting an anxious child.

In clinical settings, the program is conducted in 10 individual or group sessions with both parent and child. During each session, the parent and child receive information on the topic being covered (i.e., treatment rationale, anxiety, understanding emotions, understanding the child's experience of anxiety) and then engage in experiential learning activities including discussion, modeling, role-play, and application of new skills to real-life situations. When the program is conducted in school settings, students attend the sessions during school time, and parents are offered information sessions as well as support through phone calls. Homework assignments following each session provide the opportunity to practice new skills.

The program can be implemented by school counselors, psychologists, clinical psychologists, and other mental health care workers. In the studies included in the review, the intervention was implemented in a university-based anxiety research clinic and schools.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: September 2012
1: Anxiety disorder diagnosis
2: Anxiety disorder severity
3: Anxiety symptoms
4: Internalizing symptoms
Outcome Categories Mental health
Ages 6-12 (Childhood)
13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Non-U.S. population
Settings Outpatient
School
Geographic Locations Urban
Suburban
Implementation History Cool Kids has been implemented by more than 500 sites since its development in Australia in 1993. More than 2,000 children and adolescents have received the intervention at the primary site in Sydney, Australia, and many more have received the intervention in the United States (California and New York) and in China, Denmark, Iceland, Korea, Spain, Sweden, Turkey, and the United Kingdom.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations Cool Kids has been adapted for use with preschool-age children (Cool Little Kids Program) and for children who have an autism spectrum disorder (ASD Cool Kids Program). Another adaptation involves the use of supported self-help materials in a variety of formats. Intervention materials have been translated into many languages, including Chinese, Danish, Icelandic, Korean, Spanish, Swedish, and Turkish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: September 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Rapee, R. M., Abbott, M. A., & Lyneham, H. J. (2006). Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444.  Pub Med icon

Study 2

Hudson, J. L., Rapee, R. M., Deveney, C., Schniering, C. A., Lyneham, H. J., & Bovopoulos, N. (2009). Cognitive-behavioral treatment versus an active control for children and adolescents with anxiety disorders: A randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48(5), 533-544.  Pub Med icon

Study 3

Mifsud, C., & Rapee, R. M. (2005). Early intervention for childhood anxiety in a school setting: Outcomes for an economically disadvantaged population. Journal of the American Academy of Child and Adolescent Psychiatry, 44(10), 996-1004.  Pub Med icon

Supplementary Materials

Lyneham, H. J., Abbott, M. J., & Rapee, R. M. (2007). Interrater reliability of the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version. Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 731-736.  Pub Med icon

Kendall, P. C., Puliafico, A. C., Barmish, A. J., Choudhury, M. S., Henin, A., & Treadwell, K. S. (2007). Assessing anxiety with the Child Behavior Checklist and the Teacher Report Form. Journal of Anxiety Disorders, 21(8), 1004-1015.  Pub Med icon

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(7), 813-839.  Pub Med icon

Outcomes

Outcome 1: Anxiety disorder diagnosis
Description of Measures A diagnosis of anxiety disorder was determined using the Anxiety Disorders Interview Schedule for Children for DSM–IV: Child and Parent Versions (ADIS-CP). All children and parents were interviewed by graduate students in clinical psychology or qualified clinical psychologists who made the diagnosis on the basis of either the parent or child interview. Assessments were conducted at pretest, posttest, and 3-month follow-up. For the posttest and follow-up assessments, clinicians were blinded to the child's treatment condition.
Key Findings In a study conducted in Australia, children with an anxiety disorder (by DSM-IV criteria) and their parents were randomly assigned to a group receiving the 12-week Cool Kids intervention, a group receiving 12 weeks of bibliotherapy, or a wait-list control group. Parents and children in the intervention group participated in nine 2-hour group sessions. Parents in the bibliotherapy group received the consumer self-help book Helping Your Anxious Child: A Step-by-Step Guide and an accompanying workbook with the directive to carry out treatment at home for 12 weeks with their child. Children in the control group could enroll in the intervention at the end of the waiting period (after the posttest) but were not followed for the study. Findings from the study included the following:

  • At posttest, the proportion of children no longer meeting criteria for any DSM-IV anxiety disorder was higher in the intervention group (48.9%) than in the bibliotherapy group (17.8%; p < .001) and control group (5.7%; p < .001).
  • At 3-month follow-up, the proportion of children no longer meeting the criteria for any DSM-IV anxiety disorder remained higher in the intervention group (61.1%) than in the bibliotherapy group (18.9%; p < .001).
In another Australian study, children with an anxiety disorder (by DSM-IV criteria) and their parents were randomly assigned to either the Cool Kids intervention or a comparison condition providing group support and attention. Parents and children in both conditions participated in ten 2-hour group sessions. Sessions in the comparison condition provided a supportive environment and included activities to express and understand emotions and to build relationships between and within families, but they did not include any components of cognitive behavioral therapy. Findings from the study included the following:

  • A higher proportion of intervention than comparison group children no longer met criteria for any DSM-IV anxiety disorder at posttest (p < .05) and 3-month follow-up (p < .05).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)
Outcome 2: Anxiety disorder severity
Description of Measures Anxiety disorder severity was measured using the ADIS-CP. All children and parents were interviewed by graduate students in clinical psychology or qualified clinical psychologists. Assessments were conducted at pretest, posttest, and 3-month follow-up. For the posttest and follow-up assessments, clinicians were blinded to the child's treatment condition but were told the child's pretreatment diagnoses to ensure that they completed a measure of disorder severity (on a scale from 0 to 8) even if the child no longer met DSM-IV criteria for any anxiety disorder. Lower disorder severity scores indicate a lower level of a particular anxiety disorder, with scores of less than 4 considered to be remitted for a particular anxiety disorder.
Key Findings In a study conducted in Australia, children with an anxiety disorder (by DSM-IV criteria) and their parents were randomly assigned to a group receiving the 12-week Cool Kids intervention, a group receiving 12 weeks of bibliotherapy, or a wait-list control group. Parents and children in the intervention group participated in nine 2-hour group sessions. Parents in the bibliotherapy group received the consumer self-help book Helping Your Anxious Child: A Step-by-Step Guide and an accompanying workbook with the directive to carry out treatment at home for 12 weeks with their child. Children in the control group could enroll in the intervention at the end of the waiting period (after the posttest) but were not followed for the study. Findings from the study included the following:

  • From pre- to posttest, improvement in clinician-rated anxiety disorder severity was larger among children in the intervention group (change in ADIS-CP severity score from 6.5 to 3.4) than among those in the bibliotherapy group (change from 6.4 to 5.2; p < .001) and control group (change from 6.5 to 5.8; p < .001).
  • From pretest to 3-month follow-up, children in the intervention group had a larger improvement in clinician-rated anxiety disorder severity (change in ADIS-CP severity score from 6.5 to 2.8) than those in the bibliotherapy group (change from 6.4 to 5.0; p < .001). From posttest to 3-month follow-up, the improvement in clinician-rated anxiety disorder severity was not significantly different between these two groups.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 3: Anxiety symptoms
Description of Measures Anxiety symptoms were measured using the Spence Children's Anxiety Scale--Parent Report (SCAS-P). This measure contains 38 items about child anxiety (e.g., "My child complains of feeling afraid," "My child can't seem to get bad or silly thoughts out of his/her head") rated on a scale from 0 (never) to 3 (always). Scores range from 0 to 114, with higher scores indicating greater anxiety symptoms. In one study, data from the mother and father, when available, were combined to form a single measure of parent-rated child anxiety symptoms. When data were provided from a single parent, most often the mother, data from that parent alone were used. In another study, only data from the mother were used. Assessments were conducted at pretest, posttest, and 3-month follow-up.
Key Findings In a study conducted in Australia, children with an anxiety disorder (by DSM-IV criteria) and their parents were randomly assigned to a group receiving the 12-week Cool Kids intervention, a group receiving 12 weeks of bibliotherapy, or a wait-list control group. Parents and children in the intervention group participated in nine 2-hour group sessions. Parents in the bibliotherapy group received the consumer self-help book Helping Your Anxious Child: A Step-by-Step Guide and an accompanying workbook with the directive to carry out treatment at home for 12 weeks with their child. Children in the control group could enroll in the intervention at the end of the waiting period (after the posttest) but were not followed for the study. Findings from the study included the following:

  • From pre- to posttest, improvement in parent-reported child anxiety symptoms was larger among children in the intervention group (change in SCAS-P score from 32.0 to 23.7) than among those in the bibliotherapy group (change from 31.1 to 27.2; p < .01) and control group (change from 30.1 to 27.7; p < .001).
  • From pretest to 3-month follow-up, children in the intervention group had a larger improvement in parent-reported anxiety symptoms (change in SCAS-P score from 32.0 to 22.3) than those in the bibliotherapy group (change from 31.1 to 25.9; p = .001). From posttest to 3-month follow-up, the improvement in parent-reported child anxiety symptoms was not significantly different between these two groups.
In another Australian study, children with an anxiety disorder (by DSM-IV criteria) and their parents were randomly assigned to either the Cool Kids intervention or a comparison condition providing group support and attention. Parents and children in both conditions participated in ten 2-hour group sessions. Sessions in the comparison condition provided a supportive environment and included activities to express and understand emotions and to build relationships between and within families, but they did not include any components of cognitive behavioral therapy. Findings from the study included the following:

  • Children in the intervention group had a larger improvement in mother-reported anxiety symptoms than those in the comparison group from pretest to posttest (p < .05) and from pretest to 3-month follow-up (p < .01). However, from posttest to 3-month follow-up, the improvement in mother-reported child anxiety symptoms did not differ significantly between these two groups.
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 4: Internalizing symptoms
Description of Measures Internalizing symptoms were measured using the Internalizing Scales of the Child Behavior Checklist--Teacher Report Form (CBC-TRF). The 118-item checklist contains items scored by teachers on a 3-point scale ranging from 0 (not true) to 2 (very true or often true). Responses to a subset of items were summed to form a subscale score for internalizing symptoms. Higher scores indicate greater pathology. Assessments were conducted at pretest, posttest, and 4-month follow-up.
Key Findings In an Australian study of children with a high level of anxiety symptoms (scores of 18 or above on the Revised Children's Manifest Anxiety Scale), nine elementary schools serving the highest concentration of families disadvantaged by socioeconomic factors were randomly assigned to either the intervention group or a wait-list control group. In intervention schools, year 4 and 5 children (ages 9 and 10 years) participated in eight 1-hour group sessions, and parents were offered two optional parent sessions. Findings from the study included the following:

  • Children in intervention schools had decreases in teacher-reported internalizing symptoms compared with children in control schools from pretest to posttest (change in CBC-TRF score from 61.9 to 56.1 vs. change from 61.0 to 61.2; p = .001) and from pretest to follow-up (change in CBC-TRF score from 61.9 to 53.9 vs. change from 61.0 to 60.8; p = .001).
  • At posttest, teacher-reported internalizing symptoms did not differ significantly between children in intervention and control schools. At 4-month follow-up, however, teacher-reported internalizing symptoms were lower for children in intervention schools than for those in control schools (53.9 vs. 60.8; p < .01).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 6-12 (Childhood) 60.3% Male
39.7% Female
100% Non-U.S. population
Study 2 6-12 (Childhood)
13-17 (Adolescent)
55.8% Male
44.2% Female
100% Non-U.S. population
Study 3 6-12 (Childhood) 59% Female
41% Male
100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Anxiety disorder diagnosis 3.8 3.8 3.0 3.5 2.5 3.5 3.3
2: Anxiety disorder severity 3.8 3.5 2.0 3.5 2.5 3.5 3.1
3: Anxiety symptoms 4.0 4.0 3.0 3.5 2.5 3.5 3.4
4: Internalizing symptoms 3.5 3.5 2.0 3.5 2.5 3.3 3.0

Study Strengths

The ADIS-CP is a gold-standard instrument widely used by clinicians with psychiatric patient populations. The SCAS-P and the CBC-TRF have strong psychometric properties. Clinicians who administered the measures were blind to treatment condition. In one study, there was a high level of adherence to the manual. In all three studies, randomization at either the individual or school level reduced potential confounding variables. All three studies included both intent-to-treat and completer analyses of datasets, and two of the three studies used more sophisticated mixed and/or hierarchical linear modeling of the outcome effects.

Study Weaknesses

Intervention fidelity was weak in two of the studies. Missing data due to attrition were most likely not random across all three studies, contributing to potential confounds. None of the studies employed sophisticated modeling of missing data. Baseline group differences suggest that the block randomization protocol was not entirely successful.

Readiness for Dissemination
Review Date: September 2012

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Lyneham, H. J., Abbott, M. J., Wignall, A., & Rapee, R. M. (2003). The Cool Kids Program: Children's workbook. Sydney, Australia: Macquarie University.

Lyneham, H. J., Abbott, M. J., Wignall, A., & Rapee, R. M. (2003). The Cool Kids Program: Parent's workbook. Sydney, Australia: Macquarie University.

Lyneham, H., & Sburlati, E. (n.d.). Changing lives: Assessment and treatment strategies for child and adolescent anxiety [PowerPoint slides]. Sydney, Australia: Centre for Emotional Health, Macquarie University.

Lyneham, H. J., Schniering, C. A., Wignall, A., & Rapee, R. M. (2006). The Cool Kids Adolescent Anxiety Program parent companion. Sydney, Australia: Centre for Emotional Health, Macquarie University.

Lyneham, H. J., Schniering, C. A., Wignall, A., & Rapee, R. M. (2006). The Cool Kids Anxiety Program: Adolescent workbook. Sydney, Australia: Centre for Emotional Health, Macquarie University.

Lyneham, H., & Wuthrich, V. (2011). Assessment and treatment strategies for child and adolescent anxiety [Handout]. Sydney, Australia: Centre for Emotional Health, Macquarie University.

Outcome evaluation instruments:

  • Assessment Questionnaire Instructions
  • Children's Automatic Thoughts Scale (CATS)
  • School Anxiety Scale--Teacher Report
  • Short Mood and Feelings Questionnaire (SMFQ)
  • Spence Children's Anxiety Scale (Child Report)
  • Spence Children's Anxiety Scale (Parent Report)
  • Strengths and Difficulties Questionnaire--Child Version
  • Strengths and Difficulties Questionnaire--Parent Version
  • Strengths and Difficulties Questionnaire--Teacher Version

Program Web site, http://centreforemotionalhealth.com.au/pages/cool-kids-program.aspx

Rapee, R. M., Lyneham, H. J., Schniering, C. A., Wuthrich, V., Abbott, M. A., Hudson J. L., et al. (2006). The Cool Kids Child and Adolescent Anxiety Program therapist manual. Sydney, Australia: Centre for Emotional Health, Macquarie University.

Rapee, R. M., Lyneham, H. J., Schniering, C. A., Wuthrich, V., Abbott, M. A., Hudson, J. L., et al. (2006). The Cool Kids Child and Adolescent Anxiety Program therapist manual (school version). Sydney, Australia: Centre for Emotional Health, Macquarie University.

Training handouts:

  • Assessment and Treatment Strategies for Child and Adolescent Anxiety Workshop Outline
  • Using Detective Thinking With a Disaster

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.0 2.8 2.3 2.7

Dissemination Strengths

The therapist manuals and participant workbooks are well organized and appropriately targeted to their audiences. The therapist manuals provide clear guidance on setting up treatment groups and conducting sessions. Basic training on implementation provides information on anxiety disorders, an overview of the program model, and a description of how research findings apply to the intervention strategies. Trainings are conducted by the program developers or their highly experienced clinicians and use a combination of didactic presentations, small-group activities, role-plays, and open discussions. The developers recommend the administration of parent and child assessment tools to gather baseline information and measure client outcomes of treatment.

Dissemination Weaknesses

No cohesive guidance is provided to explain how each dissemination document fits into the implementation process. There are no organized cross-program, peer-to-peer sharing or topical learning opportunities for ongoing skill development and support beyond an advanced training workshop and consultation with the developer. Limited quality assurance tools and guidance are available to support implementation fidelity.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Therapist manual (standard or school version) AUD40 ($42) each Yes
Child workbook (for children ages 6-12) AUD20 ($21) per child Yes
Parent workbook (for parents with children ages 6-12) AUD20 ($21) per child Yes
Adolescent workbook (for adolescents ages 13-18) AUD20 ($21) per adolescent Yes
Parent companion (for parents with adolescents ages 13-18) AUD20 ($21) per adolescent Yes
Child school kit (includes school version of therapist manual, child workbook, and parent workbook) AUD65 ($68.35) each No
Adolescent school kit (includes school version of therapist manual, adolescent workbook, and parent companion) AUD65 ($68.35) each No
1-day, on-site implementation training AUD2,500 ($2,615) for up to 30 participants, plus travel expenses No
1-day, off-site implementation training in Sydney, Australia AUD320 ($335) per participant for 20-50 participants No
Consultation on site; off site in Sydney, Australia; or via phone, email, or video conference First hour free, with fees for extended hours negotiated, plus travel expenses (if on site) No
Cool Kids Adherence Measure Free No

Additional Information

Costs given in U.S. dollars are approximate and depend on the current exchange rate. Sets of workbooks (one for child/adolescent and one for parent) can be purchased singly or in bulk at a discounted rate.

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism and Developmental Disorders, 37(10), 1842-1857.  Pub Med icon

Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective intervention program for inhibited preschool-aged children of parents with an anxiety disorder: Effects on current anxiety disorders and temperament. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 602-609.  Pub Med icon

Lyneham, H. J., & Rapee, R. M. (2006). Evaluation of therapist-supported parent-implemented CBT for anxiety disorders in rural children. Behaviour Research and Therapy, 44(9), 1287-1300.  Pub Med icon

Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting and Clinical Psychology, 73(3), 488-497.  Pub Med icon

Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. American Journal of Psychiatry, 167(12), 1518-1525.  Pub Med icon

Thienemann, M., Moore, P., & Tompkins, K. (2006). A parent-only group intervention for children with anxiety disorders: Pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 45(1), 37-46.  Pub Med icon

Wuthrich, V. M., Rapee, R. M., Cunningham, M. J., Lyneham, H. J., Hudson, J. L., & Schniering, C. A. (2012). A randomized controlled trial of the Cool Teens CD-ROM computerized program for adolescent anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 51(3), 261-270.  Pub Med icon

Contact Information

To learn more about implementation or research, contact:
Heidi Lyneham, Ph.D.
+ 61 2 9850 9433
heidi.lyneham@mq.edu.au

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):