What is already known on this topic

The Cool Kids anxiety management programme for children and adolescents has demonstrated efficacy in randomised controlled trials compared with waitlist, bibliotherapy and active placebo1–3 at 3-month, 6-month and 12-month follow-ups when conducted in Australia. Further maintenance of treatment gains have been demonstrated with up to 6-year follow-up.4 Although widely used internationally, Cool Kids has not been evaluated outside Australia. Therefore, this study investigated the efficacy of this programme in a Danish population.

Methods of the study

Children and adolescents aged 7–16 years (N=109) were recruited from the local community in Denmark. Children met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for any of the anxiety disorders as their primary disorder, as indicated by the semistructured Anxiety Disorders Interview Schedule (ADIS) administered by psychologists or graduate students. Exclusion criteria were minimal, but appropriate for group treatments, with children with psychosis, untreated attention deficit hyperactivity disorder, intellectual disability and severe behaviour disorders excluded from the study.

The authors evaluated the efficacy of the manual 10 session cognitive–behavioural therapy (CBT) family programme (Cool Kids programme for anxious children and adolescents) compared with a 3-month wait list in a large randomised controlled trial.

Primary outcomes were change in diagnostic severity according to the ADIS and change on the child and parent (both mother and father) self-report measures of the Spence Child Anxiety Scale from pretreatment to post-treatment and 3-month post-treatment. An additional 12-month follow-up examined change in child and parent report on the Spence Child Anxiety Scale.

Participants were randomly allocated to Cool Kids or waitlist in blocks of 6–7 participants within set age groups according to a randomisation sequence. Assessing clinicians were blinded to treatment allocation. Follow-up was at 3 and 12 months.

What this paper adds

• This is the first randomised controlled trial demonstrating the cross-cultural effectiveness of the Cool Kids programme compared with waitlist.

• At post-treatment, significantly more youths (37 (66.1%)) in the intervention condition were free of their primary diagnosis, compared with youths (4 (7.5%)) in the wait list condition. Also, significantly more youths (27 (48.2%)) in the intervention condition were free of all anxiety diagnoses, compared with youths (3 (5.7%)) in the wait list condition.

• The results from this study report similar outcomes for changes in diagnostic severity, recovery and self-report anxiety measures at post-treatment, 3-month and 12-month follow-up shown in Australian trials of the Cool Kids programme and international trials of other CBT programmes for anxious children and adolescents.1–3

Limitations

• Overall this is a very well conducted study. One minor limitation is that clinician severity ratings were not collected at 12-month follow-up. A recent meta-analysis of psychotherapy outcomes in depressed adults found that clinician severity measures and self-report measures of treatment outcome are not equivalent and that clinician rated measures may be more sensitive to treatment outcomes.5 Therefore, a proper assessment should include both clinician rated and self-reported measures at all follow-ups.

• The treatment was compared with wait list and not to an active control condition; the majority of the ADIS interviews were conducted by students with modest prior assessment experience.

• The 12-month follow-up analyses excluded 12 participants due to their inclusion in another study on individualised treatment of non-responders.

What next in research

The next step would be to demonstrate the efficacy of this programme compared with an active control or alternative psychological intervention in a randomised controlled trial. Further research should examine which baseline factors (eg, perfectionism, parental anxiety, family cohesion) predict treatment response. Further research should also develop programmes to increase diagnosis-free outcomes, in particular for children with primary social phobia.

Do these results change your practices and why?

Yes. The results demonstrate that this programme can be used with children with a range of anxiety disorders and comorbidities with success. In practice this means there is no need to ‘exclude’ children with a particular anxiety disorder or with multiple comorbidities. Children with social phobia, however, have lower treatment outcomes in group therapy programmes compared with the other anxiety disorders and are likely to need more practice facing social fears.