Anxiety is a natural adaptive mechanism that allows us to stay alert to compromised events. A certain degree of anxiety provides an adequate component of caution against dangerous situations and allows us to face the challenges ahead. A frequent and established conceptualization is that anxiety becomes unadaptive when it interferes with daily functioning. Therefore, pathological anxiety at any age is characterized by persistent accompanying avoidance behaviors and associated with subjective distress (Beesdo et al., 2009). The prevalence of anxiety disorders (AD) is estimated in a 6’5% worldwide childhood and adolescence and produce a negative impact on their development, daily functioning and school performance (Costello et al., 2005; Polanczyk et al., 2015).
For all the above, it is essential to apply an effective treatment with the aim of improving the functioning. In many studies (Barrett, 1998; Ollendick et al., 1998; Bodden et al., 2008; Kendall et al., 2008; Lau et al., 2010; Simpson et al., 2012; Arendt et al., 2015), the Cognitive Behavioral Therapy (CBT) has been demonstrated as the one with further evidence in reducing anxious symptomatology.
Considering the format of application of CBT, the NICE Guideline (National Institute for Health and Care Excellence, 2013) recommends both individual and group formats to treat anxiety disorders in children and adolescents. Some studies have shown similar long-term benefits for individual and group formats in children with generalized anxiety disorder (GAD), separation anxiety disorder (SAD) and social phobia (SoP) in recovery rates and reduction of symptomatology (Muris et al., 2002; Gallagher et al., 2004; Silverman et al., 2008; McKinnon et al., 2018). Although the mentioned studies point to beneficial results of both CBT administrations, a meta-analysis (Reynolds et al., 2012) reported a higher effect size of the benefits within the individual format. However, the benefits on the implementation of group format are well known: a) it allows to treat a greater number of children and adolescents simultaneously, b) it provides reinforcement and modeling between peers, c) it enhances cognitive and exposure interventions and d) it provides greater cost-effectiveness benefits (Garcia-Lopez et al., 2006; Dogaheh et al., 2011; Tobon et al., 2011).
The role of parents has received a lot of attention in the literature. Parents can learn and apply contingency techniques and help in this way their children to deal with the feared stimuli and maximize the application of exposure techniques. However, previous literature has shown inconsistent results. Several studies have provided that incorporating the caregivers into the treatment generates greater effectiveness of the intervention; they evidenced improvement in the CBCL/6–18 (Child Behaviour Checklist/6–18) scores, in both internalizing and externalizing scales (Barret et al., 1998; Simpson et al., 2012). On the other hand, some authors pointed out that the involvement of parents did not have a greater effect on conventional CBT (Kendall et al., 2008; Silverman et al., 2008).
Another interesting question in previous literature is the role of the caregivers in the management of children’s anxiety when they suffer from an anxiety disorder. Some studies (Cobham et al., 1998; Hudson et al., 2014) pointed out that offspring with anxiety-free caregivers showed a better response to CBT than those with one or more caregivers with anxiety disorders. Simpson et al (2012) concluded that caregiver’s anxious behaviors played a crucial role in their children’s anxiety by maintaining their coping deficits, increasing threat expression and modeling their anxious behaviors through avoidance.
Regarding the differential response to treatment according to gender and age, the data provided by the literature are scarce. Bennett et al (2013) have not clarified whether adolescents enjoy the same level of benefit from CBT as do younger children, probably due to the lack skills of therapists to adapt available treatment manuals to the needs and characteristics of adolescents. No results have been published regarding the response to treatment according to gender.
The CBT-based "Cool Kids" (CK) program (Rapee et al., 2006) was developed by the research group of the Centre for Emotional Health, Macquarie University (Australia), to treat different anxiety disorders (GAD, SAD, SoP, specific phobia [SpP] and panic disorder [PD]) in young people between the ages of 7 and 17 years. The aim of this program for both young and their parents was to learn and cope and manage anxiety in an adaptive way through cognitive restructuring and exposure, as central elements of the treatment, along 12 sessions over 14 weeks. Its authors demonstrated their effectiveness in a randomized clinical trial, where 267 young people with a major anxiety disorder were randomly assigned to group treatment, waiting list or bibliotherapy (Rapee et al., 2006). The results showed that a higher percentage of patients assigned to the group treatment did not meet criteria for anxiety disorders after the treatment, compared to bibliotherapy and waiting list conditions.
To date, only three European studies have been carried out (in Denmark) that supported the effectiveness of CK in community and clinical contexts (Arendt et al., 2016; Djurhuus et al., 2019; Jónsson et al., 2015). In clinical and community contexts, the CK successfully decreased the interference of the anxiety symptoms observed in the CALIS (Child Anxiety Life Interference Scale; Lyneham et al., 2013) scores at post-treatment. These effects remained stable at 3 and 12 months of follow-up (Djurhuus et al., 2019). Also, the self-reported and parent versions of the Spence Children's Anxiety Scale (SCAS, Spence, 1998) showed also a reduction of the anxious severity compared to the waiting list (Jónsson et al., 2015; Arendt et al., 2016).
The aim of the current study was to validate and analyze the effectiveness of the Spanish adaptation of CK in a clinical sample of children and youth with anxiety disorders, in a group format that includes the active collaboration of parents. A secondary aim was to explore gender and age differences in the response to the treatment.
Our hypothesis was that, after the intervention, there will be a significant reduction of anxiety severity and its interference over life activities, both in self-reported and reported by parent’s questionnaires.