Joint runner up in the Guidelines in Practice Award 2005 was an innovative project to reduce childhood emotional disorders. Team leader Professor Paul Stallard describes the initiative


Emotional disorders may affect as many as 20% of children, of whom almost half will require specialist intervention.1 These disorders can significantly affect children’s interpersonal and academic functioning and, without treatment, can have a chronic and unremitting course.1

However, few children with significant emotional disorders receive specialist help. A recent survey found that over an 18-month period only one-fifth of children with significant mental health problems received help from specialist child and adolescent mental health services.2

Randomised controlled trials have shown that cognitive behavioural therapy is effective in a range of emotional disorders.3,4 The challenge is to make interventions such as cognitive behavioural therapy more widely available.


The National Service Framework for Children,Young People and Maternity Services sets out the Government’s 10-year plan to improve health services for these groups.5 The NSF emphasises the importance of a multi-agency approach to provide services that are child-centred and to enable problems to be identified early.

Standard 9, which relates to mental health and psychological wellbeing, states that all children and young people with mental health disorders should have access to “timely, integrated, high quality multidisciplinary mental health services to ensure effective assessment, treatment and support, for them, and their families”. A consultation document identifies the principles on which these services should be based (Box 1, below).6

Box 1: Principles on which mental health services for children and young people should be based
  • Services should be comprehensive and include prevention and early intervention services
  • Children, young people and their families should be involved at all stages and levels of the design and provision of services
  • Services should be offered as near to home as possible in a number of settings, including schools
  • Specialist child mental health services must work in partnership with other agencies and professionals
  • There should be an evidence-based approach to clinical practice
  • All services should routinely audit and evaluate their work


In September 2003, we began our initiative to address emotional disorders in children in the Bath & North East Somerset Council area.We concentrated on the three geographical areas with the highest rates of social and economic disadvantage.

A team was established, composed of staff from Avon and Wiltshire Mental Health Partnership NHS Trust’s Child and Adolescent Mental Health Service, the University of Bath, and Bath & North East Somerset Primary Care Trust. Barnardo’s administered the funding, which came from the Children’s Fund.This is a Government funding stream for the development of services for children aged 5 to 13 years who are at risk of social exclusion.7

We carried out a full needs assessment and literature review. We also consulted widely with children as well as professionals before selecting the FRIENDS programme as the emotional health intervention for the area.


FRIENDS is a programme of cognitive behavioural therapy that promotes emotional resilience, reducing anxiety and increasing self-esteem, in schoolchildren.

The programme,of structured weekly one-hour sessions over a 10-week period, is delivered by specially trained school nurses to whole classes. This enables as many children as possible, regardless of their emotional status, to benefit.

Randomised controlled trials have found that when FRIENDS is provided as a universal intervention to whole classes in schools, children demonstrate a significant reduction in anxiety symptoms and that these improvements are maintained for up to 3 years.8,9

The World Health Organization has found that strategies that strengthen the emotional resilience and cognitive skills of children help to avoid the development of emotional disorders. The WHO has endorsed FRIENDS as a promising universal school-based anxiety prevention programme.10

Despite this, FRIENDS, which was developed in Australia, is not routinely provided in the UK. In fact, our initiative is the first to use FRIENDS routinely as a universal preventative programme in this country.


There is evidence that FRIENDS may be more effective in younger children, so we chose to target children aged 9-10 years.11 We invited 21 schools in the three priority areas to participate in the project and 20 agreed to take part.

All the parents of children in the classes targeted were informed about the programme before its start; 844 children were eligible to take part in the first 10-session programme and parental permission was refused for only one child.

School nurses underwent two-day training sessions to become familiar with the FRIENDS programme and the theory of cognitive behavioural therapy. Every nurse was supplied with a manual detailing the structure of each of the 10 sessions, to enable them to deliver the sessions with the aid of the class teachers.

The first sessions took place in March 2004. During the programme, children are taught practical skills to enable them to identify their feelings of anxiety, to learn to relax, and to identify thoughts that increase anxiety and replace them with more helpful ones.

They are also taught how to face and overcome problems and challenges. Every child has a workbook to complete as the programme progresses.

Supervision takes place through monthly meetings between the nurses and a child mental health specialist.A review is held at the end of each programme to enable problems to be identified and materials modified.


Six schools, two from each of the geographical priority areas, were selected as assessment schools. Some 213 children in these six schools completed the Spence Children’s Anxiety Scale,12 and the Culture-Free Self-Esteem Questionnaire Form B,13 before and after FRIENDS.

Matched pre- and post-intervention data were available for 197 children, which showed that after FRIENDS self-esteem had significantly improved, while levels of anxiety were significantly reduced (Table 1, below).14

Table 1: Assessment scores before and after FRIENDS*
Spence Children’s Anxiety Scale (total)
Panic symptoms
Separation anxiety
Fears about physical injury
Social phobia
Obsessive-compulsive symptoms
Generalised anxiety
Culture-Free Self-Esteem Questionnaire (total)
General self-esteem
Social self-esteem
Academic self-esteem
Parental self-esteem


* 197 children were assessed

We also undertook analysis on the 10% of children with the highest anxiety or lowest self-esteem scores before FRIENDS (the ‘high-risk’ group).We found that more than half of these children showed significant improvements.

Some 190 children took part in the qualitative evaluation of the programme (Table 2, below).

Table 2: What children felt about the FRIENDS programme*
A little
Did you understand most of the work?
Did you feel safe talking about yourself?
Were you listened to?
Was it fun?
Do you think it has helped you?
Did you learn anything new?
Were you given enough time to do the work?
Did your family think FRIENDS was good?
Have you helped anyone with your new skills?
Would you recommend it to a friend?
* 190 children evaluated the programme

This showed that more than threequarters thought the programme was fun and a similar proportion would recommend it to a friend. More than two-thirds had learned new skills and almost half had used their new skills to help someone else.

School nurses and teachers who have participated in FRIENDS say that they have incorporated many of the skills and ideas of cognitive behavioural therapy into their everyday practice, to good effect.


By the end of July 2005, our second year, we had delivered the FRIENDS programme to almost 1500 children aged 9-10 years.

This is an important step towards tackling emotional disorders in children in the three most socially deprived areas within the Bath & North East Somerset area, in line with the principles of the NSF.

The local team hope to become accredited FRIENDS trainers soon, thereby allowing us to train others to deliver the programme.

Plans are under way to offer FRIENDS to other schools in Bath and North East Somerset through the ‘Healthy Schools Programme’ and to increase the amount of time school nurses can spend delivering FRIENDS as part of the ‘Choosing Health: making healthy choices easier’ initiative.


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  2. Ford T,Goodman R, Meltzer H. Service use over 18 months among a nationally representative sample of British children with psychiatric disorder. Clin Child Psychol Psychiatry 2003; 8: 37-51.
  3. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 1994; 62:100-10.
  4. Kendall PC, Flannery-Schroeder E, Panichelli- Mindel SM et al. Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 1997; 65: 366-80.
  5. Department of Health. National Service Framework for Children, Young People and Maternity Services. London: DoH, 2004.
  6. Department of Health. Getting the right start: The National Service Framework for Children, Young People and Maternity Services – Emerging findings. London: DoH, 2003.
  7. Department for Education and Skills. Children’s Fund Guidance. London: DFES, 2003.
  8. Lowry-Webster HM, Barrett PM, Dadds MR. A universal prevention trial of anxiety and depressive symptomatology in childhood: preliminary data from an Australian study. Behaviour Change 2001; 18: 36-50.
  9. Barrett PM, Farrell LJ, Ollendick TH, Dadds M. Long-term outcomes of an Australian universal prevention trial of anxiety and depression symtoms in children and youth: An evaluation of the FRIENDS programme. (Submitted)
  10. World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: WHO, 2004.
  11. Lock S, Barrett PM. A longitudinal study of developmental differences in a universal preventive intervention for child anxiety. Behaviour Change 2003; 20: 183-99.
  12. Spence SH. The Spence Children’s Anxiety Scale (SCAS). In: Sclare I, ed. Child Psychology Portfolio.Windsor: NFER-Nelson, 1997.
  13. Battle J. Culture-Free Self-Esteem Inventories (second edition). Austin,Texas: Pro-Ed, 1992.
  14. Stallard P, Simpson N, Anderson S et al. An evaluation of the FRIENDS programme – a cognitive behaviour therapy intervention to promote emotional resilience. Arch Dis Child 2005; 90: 1016-19.

Guidelines in Practice, January 2006, Volume 9(1)
© 2006 MGP Ltd
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