Intervention Summary

FRIENDS Program

The FRIENDS Program is a cognitive behavioral intervention that focuses on the promotion of emotional resilience to prevent--or intervene early in the course of--anxiety and depression in childhood, adolescence, and adulthood. It is intended for use both as a self-development course and as an intervention, and it helps participants in developing social and emotional skills to effectively cope with challenging situations.

The FRIENDS Program is delivered to participants through four developmentally appropriate versions:

Fun FRIENDS, for children ages 4-7
FRIENDS for Life, for children ages 8-11
My FRIENDS Youth, for adolescents ages 12-15
Adult Resilience, for older adolescents (ages 16 and older) and adults

Each version is based on a theoretical model that addresses the attachment, physiological, cognitive, and learning processes that interact in the development, maintenance, and experience of anxiety. Core elements are delivered through play-based activities and experiential learning for younger children and group discussion, hands-on activities, and role-play for older children, adolescents, and adults.

Each version of the FRIENDS Program consists of 10 weekly sessions as well as 2 booster sessions held at 1- and 3-month intervals following program completion. Two sessions are also held for parents (typically at the beginning and halfway point of the program). The FRIENDS Program can be delivered by teachers, psychologists, nurses, social workers, or school counselors after they have completed facilitator training. The training covers the psychopathology of depression and anxiety, risk and protective factors, resilience development, the theoretical basis of the program (cognitive behavioral therapy and positive psychology), and a detailed description of the program's implementation.

The studies reviewed for this summary included the following versions of the FRIENDS Program: Fun FRIENDS, FRIENDS for Children (an older version of FRIENDS for Life), and FRIENDS for Youth (an older version of My FRIENDS Youth).

Descriptive Information

Areas of Interest	Mental health promotion
Outcomes	1: Anxiety 2: Depression 3: Coping 4: Social-emotional strength
Outcome Categories	Mental health Social functioning
Ages	0-5 (Early childhood) 6-12 (Childhood) 13-17 (Adolescent)
Genders	Male Female
Races/Ethnicities	Non-U.S. population
Settings	School
Geographic Locations	Urban
Implementation History	Since its development, the FRIENDS Program has been delivered to an estimated 800,000 children and adolescents worldwide. The program is in use in schools and clinics in the following countries: Australia, Brazil, Canada, Finland, Germany, Hong Kong, Ireland, Japan, Mexico, the Netherlands, New Zealand, Norway, Peru, Portugal, Singapore, South Africa, Sweden, the United Kingdom, and the United States. In Australia, over 300 schools and 200 hospitals and health services use the FRIENDS Program, and all children in Ireland receive the FRIENDS Program as part of their curriculum. In British Columbia, Canada, the Ministry of Children and Family Development has funded and coordinated the FRIENDS Program, training more than 6,000 teachers and educators to deliver the program in kindergarten through seventh-grade classrooms as part of the students' curriculum. The FRIENDS Program is the only childhood anxiety prevention program acknowledged by the World Health Organization for more than 15 years of comprehensive evaluation and practice.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: No
Adaptations	The FRIENDS Program has been translated into Chinese, Dutch, Finnish, Japanese, Norwegian, Portuguese, Spanish, and Swedish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Universal

Quality of Research

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

Barrett, P., & Turner, C. Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40(4), 399-410.

Study 2

Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: An evaluation of the FRIENDS Program. Journal of Clinical Child and Adolescent Psychology, 35(3), 403-411.

Lock, S., & Barrett, P. A longitudinal study of developmental differences in universal preventive intervention for child anxiety. Behaviour Change, 20(4), 183-199.

Study 3

Pahl, K. M., & Barrett, P. M. Preventing anxiety and promoting social and emotional strength in preschool children: A universal evaluation of the Fun FRIENDS Program. Advances in School Mental Health Promotion, 3(3), 14-25.

Supplementary Materials

Spence, S. H., Barrett, P. M., & Turner, C. M. Psychometric properties of the Spence Children's Anxiety Scale with young adolescents. Journal of Anxiety Disorders, 17(6), 605-625.

Outcomes

Outcome 1: Anxiety
Description of Measures	Anxiety was assessed using three measures: The Spence Children's Anxiety Scale (SCAS), a 44-item self-report questionnaire designed for use with children ages 8-12. Thirty-eight items assess the frequency of specific types of anxiety (e.g., social phobia, separation anxiety), and six items are positive "control" questions to adjust for negative response bias. Using a scale ranging from 0 (never) to 3 (always), participants rate each item. All items are summed to produce a single score. The Revised Child Manifest Anxiety Scale (RCMAS), a 37-item self-report questionnaire. Twenty-eight items assess chronic/trait anxiety symptoms, and nine items assess social desirability (as a control for possible untruthful answers). Each item is rated by the respondent as true (1) or untrue (0), and ratings for all items are summed to produce a single score. The Preschool Anxiety Scale, Parent Report (PAS), which consists of 28 anxiety-based items, 5 unscored posttraumatic distress items, and 1 open-ended item on traumatic events. Each of the anxiety-based items is rated by the respondent on a scale ranging from 0 (not at all) to 4 (very often true), and ratings for these items are summed to form a total score, which ranges from 0 to 112.
Key Findings	A study was conducted in Australia with students in grade 6. Schools of varying levels of socioeconomic advantage and religious affiliation were randomly assigned to one of three conditions: psychologist-led intervention, teacher-led intervention, or usual care. In the intervention schools, students received the FRIENDS Program through weekly 75-minute sessions over 10 weeks (typically during social science classes) and through two booster sessions held 1 and 3 months after the last weekly session; in addition, parents of students in the intervention schools were offered four evening sessions throughout the program. Students in the usual care schools received the standard curriculum. All students were assessed before (pretest) and after (posttest) the 10-week intervention period. From pre- to posttest, students who received the psychologist- or teacher-led intervention had a greater reduction in anxiety compared with students who received usual care (p < .05 for both the SCAS and the RCMAS). There was no significant difference in the improvement between students who received the psychologist-led intervention and those who received the teacher-led intervention. A second study was conducted in Australia with students in grades 6 and 9. Schools were matched on the basis of geographic location, and one school from each pair was randomly assigned to the intervention condition or the wait-list control condition. In the intervention schools, students received the FRIENDS Program through weekly 70-minute sessions over 10 weeks as part of the curriculum within the subject areas of health and physical education or social and personal development; in addition, the parents of students in the intervention schools were offered four evening sessions throughout the program. Students in the control schools received the standard curriculum. All students were assessed before (pretest) and after (posttest) the 10-week intervention period and at 12-, 24-, and 36-month follow-ups. From pre- to posttest, students who received the intervention had a greater reduction in anxiety compared with students in the control schools (p < .016 for both the SCAS and the RCMAS); this finding also was present at the 12-month follow-up (p < .016 for both the SCAS and the RCMAS). Among students who were in grade 6 at the beginning of the study, those who received the intervention also had lower anxiety across the 24- and 36-month follow-ups compared with students in the control schools (p < .01 for the SCAS and p < .05 for the RCMAS). There was no significant difference by group for students who were in grade 9 at the beginning of the study. In a third study conducted in Australia, preschool classes were matched on the basis of socioeconomic status, class size, and gender balance and then randomly assigned to the intervention condition or the wait-list control condition. In the intervention classes, children received the FRIENDS Program through weekly 60-minute sessions over 9 weeks as part of the curriculum within the subject areas of health and physical education or social and personal development; in addition, the parents of children in the intervention classes were offered four evening sessions throughout the program. Children in the control classes received the standard curriculum. All parents were assessed before (pretest) and after (posttest) the 9-week intervention period, and parents of children in the intervention classes also were assessed at a 12-month follow-up. From pre- to posttest, as measured by the PAS, there was no significant difference in the anxiety levels of children in the intervention and control classes. However, from pretest to the 12-month follow-up, children who received the intervention (i.e., those in the intervention or wait-list control classes) had a reduction in anxiety (p < .05).
Studies Measuring Outcome	Study 1, Study 2, Study 3
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 2: Depression
Description of Measures	Depression was assessed using the Child Depression Inventory (CDI), a 27-item self-report questionnaire designed for use with children ages 7-17. Items measure cognitive, affective, and behavioral symptoms of depression (e.g., sadness, insomnia, school adjustment), which respondents rate on a scale of 0 (none), 1 (mild), or 2 (severe). Ratings for all items are summed to produce a single score.
Key Findings	A study was conducted in Australia with students in grades 6 and 9. Schools were matched on the basis of geographic location, and one school from each pair was randomly assigned to the intervention condition or the wait-list control condition. In the intervention schools, students received the FRIENDS Program through weekly 70-minute sessions over 10 weeks as part of the curriculum within the subject areas of health and physical education or social and personal development; in addition, the parents of students in the intervention schools were offered four evening sessions throughout the program. Students in the control schools received the standard curriculum. All students were assessed before (pretest) and after (posttest) the 10-week intervention period and at 12-, 24-, and 36-month follow-ups. From pre- to posttest, students who received the intervention had a greater reduction in depression compared with students in the control schools (p < .016); this finding also was present at the 12-month follow-up (p < .016). Across the 24- and 36-month follow-ups, no significant differences in depression were found between students in the intervention and control schools.
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 3: Coping
Description of Measures	Coping was assessed using the Coping Scale for Children and Youth (CSCY), a 29-item self-report questionnaire designed for use with children ages 10-15. Each item represents a coping method, and using a scale ranging from 1 (never) to 4 (very often), respondents rate how frequently they use each item. Ratings for items are grouped and summed to produce four subscale scores: assistance seeking, cognitive-behavioral problem-solving, cognitive avoidance, and behavioral avoidance.
Key Findings	A study was conducted in Australia with students in grades 6 and 9. Schools were matched on the basis of geographic location, and one school from each pair was randomly assigned to the intervention condition or the wait-list control condition. In the intervention schools, students received the FRIENDS Program through weekly 70-minute sessions over 10 weeks as part of the curriculum within the subject areas of health and physical education or social and personal development; in addition, the parents of students in the intervention schools were offered four evening sessions throughout the program. Students in the control schools received the standard curriculum. All students were assessed before (pretest) and after (posttest) the 10-week intervention period and at 12-month follow-up. From pre- to posttest, students who received the intervention had a greater reduction in behavioral avoidance compared with students in the control schools (p < .0125); this finding also was present at the 12-month follow-up (p < .0125). There were no significant differences by group for the other subscales.
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 4: Social-emotional strength
Description of Measures	Social-emotional strength was measured using the Behavioral and Emotional Rating Scale-Teacher Report, a 52-item questionnaire assessing teacher impressions of emotional and behavioral strengths in children. Using a 4-point scale ranging from 0 (not at all like this child) to 3 (very much like this child), teachers rate each item, which describes a trait or quality (e.g., "attends school regularly"). Ratings for all items are summed to form a total score.
Key Findings	In a study conducted in Australia, preschool classes were matched on the basis of socioeconomic status, class size, and gender balance and then randomly assigned to the intervention condition or the wait-list control condition. In the intervention classes, children received the FRIENDS Program through weekly 60-minute sessions over 9 weeks as part of the curriculum within the subject areas of health and physical education or social and personal development; in addition, the parents of children in the intervention classes were offered four evening sessions throughout the program. Children in the control classes received the standard curriculum. All teacher's impressions were assessed before (pretest) and after (posttest) the 9-week intervention period. From pre- to posttest, students who received the intervention had a greater improvement in social-emotional strength compared with students in the control classes (p < .005).
Studies Measuring Outcome	Study 3
Study Designs	Experimental
Quality of Research Rating	2.8 (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)	50.5% Male 49.5% Female	100% Non-U.S. population
Study 2	6-12 (Childhood) 13-17 (Adolescent)	50.3% Female 49.7% Male	100% Non-U.S. population
Study 3	0-5 (Early childhood) 6-12 (Childhood)	52.1% Male 47.9% Female	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:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
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	2.8	3.0	2.4	2.6	2.9	2.8	2.7
2: Depression	2.9	2.8	2.1	2.6	2.9	2.9	2.7
3: Coping	2.9	2.9	2.1	2.6	2.9	2.9	2.7
4: Social-emotional strength	3.0	3.0	2.2	2.7	2.9	2.8	2.8

Study Strengths

The RCMAS has sound psychometric properties, including high internal reliability and moderate test-retest reliability. The SCAS has demonstrated high internal reliability. The RCMAS has been shown to have acceptable forms of criterion-related validity, correlating well with the State-Trait Anxiety Inventory for Children and other measures. Reliability and validity of the CSCY have been documented in the literature and by independent investigators. The Behavioral and Emotional Rating Scale-Teacher Report had generally good psychometric properties. The intervention was manualized, and some sessions were observed and recorded. Self-report by group leaders showed a high concordance rate between sessions and manual content. Attrition was low in two studies, and missing data were minimal in all studies. Excellent statistical procedures were used, as well as practical conceptualization of the missing data problem. In all three studies, randomization plus examination of gender account for a number of confounds. Data analytic strategies were appropriate and controlled for a number of potential confounding variables.

Study Weaknesses

Test-retest reliability of the SCAS is considered low to fair. There was a concern that reliability data were not applicable to sixth graders who participated in the study. Although the CDI and the CSCY have been identified as instruments with known psychometric properties, information on the reliability and validity of the measures' use with the specific study sample was not identified in the study documents. Despite observation, recording, and self-reporting by group leaders, no psychometric properties of the fidelity measures were reported. Attrition was substantial in one study and imprecisely reported in another. High rates of missing parent data were a concern.

Readiness for Dissemination

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.

Barrett, P. Fun FRIENDS: A facilitator's guide to building resilience in 4 to 7 year-old children through play. West End, Queensland, Australia: Fun Friends Publishing, Pathways Health and Research Centre.

Barrett, P. Fun FRIENDS: A parent's guide to building resilience in 4 to 7 year-old children through play. West End, Queensland, Australia: Fun Friends Publishing, Pathways Health and Research Centre.

Barrett, P. FRIENDS for Life: Activity book for children. West End, Queensland, Australia: Pathways Health and Research Centre.

Barrett, P. FRIENDS for Life: Group leaders' manual for children. West End, Queensland, Australia: Pathways Health and Research Centre.

Barrett, P. My FRIENDS youth resilience program: Activity book for youth. West End, Queensland, Australia: Pathways Health and Research Centre.

Barrett, P. My FRIENDS youth resilience program: Group leaders' manual for youth. West End, Queensland, Australia: Pathways Health and Research Centre.

Barrett, P. Resilient families parenting session--FRIENDS for Life: Parent workshop 1: Induction [PowerPoint slides]. West End, Queensland, Australia: Pathways Health and Research Centre.

Barrett, P. Resilient families parenting session--The healthy family step plan: FRIENDS for Life [PowerPoint slides]. West End, Queensland, Australia: Pathways Health and Research Centre.

Pathways Health and Research Centre. Licensee CD: Fun FRIENDS, FRIENDS for Life, My FRIENDS youth programs. West End, Queensland, Australia: Author.

Quality assurance tools:

Behaviour Intervention Rating Scale, Parent Report
Behaviour Intervention Rating Scale, Teacher Report
Behavioural and Emotional Rating Scale, Parent and Teacher Report
Behavioural Inhibition Questionnaire, Parent and Teacher Report
FRIENDS for Life Intervention Integrity Checklist
FRIENDS Knowledge and Self-Efficacy Scale--Part I: Ratings of Confidence Implementing the FRIENDS Program Into Your Setting
FRIENDS Knowledge and Self-Efficacy Scale--Part II: Knowledge Test
Friends Support Materials for Program Evaluation: Instruments Used in Intervention Research
FRIENDS Training Workshop Feedback Questionnaire--Part A: General Feedback for Workshop Training
Fun FRIENDS Intervention Integrity Checklist
My FRIENDS Intervention Integrity Checklist
Survey on Global Satisfaction: Friends Program Social Validity

Research articles:

Barrett, P., & Turner, C. Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. British Journal of Clinical Psychology, 40(4), 399-410.
Barrett, P. M., Duffy, A. L., Dadds, M. R., & Rapee, R. M. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6-year) follow-up. Journal of Consulting and Clinical Psychology, 69(1), 135-141.
Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: An evaluation of the FRIENDS Program. Journal of Clinical Child and Adolescent Psychology, 35(3), 403-411.
Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., & Laurens, K. R. Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology, 65(4), 627-635.
Fisak, B. J., Jr., Richard, D., & Mann, A. The prevention of child and adolescent anxiety: A meta-analytic review. Prevention Science, 12(3), 255-268.
Lowry-Webster, H. M., Barrett, P. M., & Dadds, M. A universal prevention trial of anxiety and depressive symptomology in childhood: Preliminary data from an Australian study. Behaviour Change, 18(1), 36-50.
Lowry-Webster, H. M., Barrett, P. M., & Lock, S. A universal prevention trial of anxiety symptomology during childhood: Results at 1-year follow-up. Behaviour Change, 20(1), 25-43.
Neil, A. L., & Christensen, H. Efficacy and effectiveness of school-based prevention and early intervention programs for anxiety. Clinical Psychology Review, 29(3), 208-215.
Pahl, K. M., & Barrett, P. M. Preventing anxiety and promoting social and emotional strength in preschool children: A universal evaluation of the Fun FRIENDS Program. Advances in School Mental Health Promotion, 3(3), 14-25.
Shortt, A. L., Barrett, P. M., & Fox, T. L. Evaluating the FRIENDS Program: A cognitive-behavioral group treatment for anxious children and their parents. Journal of Clinical Child Psychology, 30(4), 525-535.
Stallard, P., Simpson, N., Anderson, S., & Goddard, M. The FRIENDS emotional health prevention programme: 12 month follow-up of a universal UK school based trial. European Child and Adolescent Psychiatry, 17(5), 283-289.
Stopa, J. E., Barrett, P. M., & Golinga, F. The prevention of childhood anxiety in socioeconomically disadvantaged communities: A universal school-based trial. Advances in School Mental Health Promotion, 3(4), 5-24.

Tools for evaluation (used in research):

Anxiety Disorders Interview Schedule for DSM-IV, Child Version: Parent Interview Schedule
Children's Depression Inventory
Coping Scale for Children and Youth
Depression, Anxiety, and Stress Scale
Parenting Stress Index (PSI) [Adapted from the PSI Short Form by Richard R. Abidin]
Preschool Anxiety Scale, Parent Report
Prevention of Anxiety in Disadvantaged Communities
Revised Children's Manifest of Anxiety Scale
Self Esteem Questionnaire
Spence Child Anxiety Scale
Strength and Difficulties Questionnaire

Additional documents:

Emotional and Resilience Programs [Informational brochure]
Pathways Health and Research Centre. FRIENDS for Life and Fun FRIENDS evidence base abstracts. West End, Queensland, Australia: Author.
The FRIENDS Programs: Emotional and Resilience Programs, [Informational brochure]
World Health Organization.. Prevention of mental disorders: Effective interventions and policy options, summary report. Geneva, Switzerland: Author.

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

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

Availability of implementation materials
Availability of training and support resources
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
4.0	3.5	3.3	3.6

Dissemination Strengths

The manuals for group leaders and the activity books for children and youth are well designed and visually engaging. They are also developmentally appropriate for use with each age group and address cultural diversity. The manuals for group leaders provide session-by-session support and guidance on which materials to use throughout program implementation. The manuals also support group leaders' flexibility and creativity in program delivery. Guidance on how to include parents and community members is provided, as is information on elements of effective group leadership. The program Web site offers additional group activities and program updates for group leaders. The required training covers all program sessions and encourages participants to apply the concepts and principles to their specific context. Several quality assurance forms are required and provide a structure for assessing group leaders' adherence to the program model and their levels of skills in conducting program sessions. In addition, research sites use several standardized assessment instruments to measure participants' initial levels of mental illness symptoms and the outcomes of the program.

Dissemination Weaknesses

The training does not appear to include time for practice before implementation. Coaching is limited, including the support available for facilitators who do not have experience with interventions based on cognitive behavioral theories. Written guidance is not provided on program evaluation or quality assurance processes for universal implementation of the program. Information is limited on the protocol for collecting, analyzing, and applying data on program outcomes for children.

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
Activity books for each version of the program (i.e., Fun FRIENDS, FRIENDS for Life, My FRIENDS Youth, Adult Resilience)	AUD20 ($19.10) each	Yes
Group leaders' manual for each version of the program	AUD30 ($28.64) each	Yes
1-day, online facilitator training for two of the four program versions (includes group leaders' manuals, activity books, and access to additional resources for download)	AUD290 ($276.89.00) per participant or AUD2,900 ($2,768.88) for groups of 8-50 people	Yes, one of the facilitator trainings is required
1-day, on-site facilitator training for two of the four program versions (includes group leaders' manuals, activity books, and access to additional resources for download) for 8-50 participants	AUD400 ($381.97) per participant, plus travel expenses	Yes, one of the facilitator trainings is required
2-day, online facilitator training for all four program versions (includes group leaders' manuals, activity books, and access to additional resources for download)	AUD490 ($467.85) per participant or AUD4,900 ($4,678.45) for groups of 8-50 people	Yes, one of the facilitator trainings is required
2-day, on-site facilitator training for all four program versions (includes group leaders' manuals, activity books, and access to additional resources for download) for 8-50 participants	AUD2,000 ($1,909.57) plus travel expenses	Yes, one of the facilitator trainings is required
Parent information session presentations and program notes	Free	Yes
Phone consultation and email support	Free	No
Online resources (e.g., implementation checklist, example letter to parents and community)	Free	No
Online training	AUD380	Yes
Online activity book	AUD5	Yes
Online manual for facilitators (e.g., teachers, psychologists)	AUD10	Yes

Additional Information

Costs given in U.S. dollars are approximate and depend on the current exchange rate. Costs of the activity books and group leaders' manuals may be negotiable for large, ongoing orders.