How can we prevent anxiety disorders? - Chapter 21

What is this chapter about?

An anxiety disorder often starts in childhood or adolescence and becomes chronic if it is left untreated. 50-60% of children benefit from treatment of anxiety disorders, but a large proportion continues to experience problems. This is why there is more and more emphasis on prevention rather than the treatment of anxiety disorders. As mentioned earlier, there are three approaches for prevention: universal (for the entire population, regardless of their risk), indicated (children with symptoms, but who do not yet meet the diagnostic criteria), and selective (children at greater risk due to psychological, biological or environmental risk factors).

What does universal prevention mean?

Universal prevention programs do not require screening for anxiety or other risk factors. This type of program is usually used within school setting, but outside school hours. A common problem here is the motivation of the child, as many parents or children do not see the point of it. To get around this issue, the program is better offered during school hours. A well-known universal prevention program is called FRIENDS. FRIENDS can be targeted at two groups: children (7-11 years) and young people (12-16 years) and is based on the CBT. It consists of ten weekly sessions and psycho-education, relaxation, positive self-talk, gradual exposure, problem solving, and rewards. There is a lot of scientific support for long-term effectiveness in reducing anxiety symptoms in school-aged children. In general, such programs have a small but significant preventive effect on anxiety in older children and adolescents. A major disadvantage of such prevention programmes is that a great deal of time and effort is invested in children who do not need it, so that universal prevention does not logically appear as cost-effective as targeted prevention programmes.

What does (targeted) indicated prevention consist of?

Although (targeted) indicated prevention is aimed at children who show symptoms but do not yet meet the diagnostic criteria, it is sometimes difficult to determine who is the target of this prevention. This type of prevention is also often offered at school. The impact is greater than of universal programmes, because the children who receive this intervention do need help. Studies on the effectiveness of the program show mixed results, which is probably due to factors such as selection strategy, or the background and training of the therapist. Given the accessibility, cost-effectiveness and easy integration of this programme, more research needs to be done on the best way to achieve the best possible results.

What does (targeted) selective prevention consist of?

The (targeted) selective prevention programme focuses on children who are at increased risk of developing a particular disorder, due to vulnerability factors known to increase the risk of that disorder. Risk factors for anxiety disorders mainly include the presence of anxiety disorders in the parents, the behavioural inhibition of the child and a certain information processing style. In terms of anxiety disorders in parents, it is often the case that children are at increased risk of developing an anxiety disorder. The genetic part is not entirely clear: it seems that the children do not inherit a specific anxiety disorder, but rather a more general (possibly temperamental) vulnerability. Behavioural inhibition (BI) is a temperament that has received the most attention as a risk factor for anxiety disorders. BI is stable and is characterized by fear or restraint in unfamiliar situations or in situations with unknown people. Finally, the information processing style is also a risk factor: both in terms of attention bias in relation to threatening information, and the bias in interpreting ambiguous material.

Targeted selective prevention programs targeting school-age children who have one of these three risk factors – the presence of anxiety disorders in parents, high levels of BI and/or a disrupted information processing style – are promising. In particular, the important role of parental anxiety and BI has been implied multiple times and needs to be targeted to prevent the anxiety disorder. More research needs to be done to find out the precise role of the information processing style in relation to the onset of an anxiety disorder.

What can be concluded?

There is a lot of evidence for the effectiveness of prevention programs for anxiety in children and adolescents. The outcomes are as effective as prevention programs for other disorders (such as depression or an eating disorder). There are positive outcomes for all three prevention approaches (universal, indicated, selective) and the improvements (less anxiety symptoms) often last for a long time, at least about 6 to 12 months. More research is needed to determine whether the improvements are stable over the long-term. The best results come from selective interventions. However, the theoretical status "preventive" does not always apply here, since there is a good chance that in this type of programmes, children who are already actually suffering from the disorder are treated in this way. Furthermore, surprisingly little research has been done on the relative cost-effectiveness of all three types of programmes, something which desperately needs to be explored.

An anxiety disorder often starts in childhood or adolescence and becomes chronic if it is left untreated. 50-60% of children benefit from treatment of anxiety disorders, but a large proportion continues to experience problems. This is why there is more and more emphasis on prevention rather than the treatment of anxiety disorders. As mentioned earlier, there are three approaches for prevention: universal (for the entire population, regardless of their risk), indicated (children with symptoms, but who do not yet meet the diagnostic criteria), and selective (children at greater risk due to psychological, biological or environmental risk factors).