A comparison of universal school-based prevention programs for children: building resilience to manage worry

Author: Kristy Johnstone

Johnstone, Kristy, 2020 A comparison of universal school-based prevention programs for children: building resilience to manage worry, Flinders University, College of Education, Psychology and Social Work

Terms of Use: This electronic version is (or will be) made publicly available by Flinders University in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. You may use this material for uses permitted under the Copyright Act 1968. If you are the owner of any included third party copyright material and/or you believe that any material has been made available without permission of the copyright owner please contact copyright@flinders.edu.au with the details.


Anxiety and depression are prevalent in child populations, and can negatively impact a child’s emotional, social, and cognitive development. However, these disorders tend to remain undiagnosed in children, leading to a prolonged negative impact on functioning and quality of life. Moreover, the high rates of comorbidity between anxiety and depression often lead to more chronic symptomology and a poorer response to treatment. Thus, preventing the onset of anxiety and depression in childhood may be beneficial.

The purpose of this thesis was to develop and investigate the efficacy of universal school-based prevention programs for children. The research began by conducting a meta-analysis of previous anxiety and depression prevention programs. Its results showed that most programs demonstrated small or null effects for the reduction and prevention of symptomology, with very few studies showing benefits for reducing both anxiety and depression together. Two limitations were suggested to account for the small effects. First, all programs were based on Cognitive Behavioural Therapy (CBT); however, it has been suggested that children may not possess the cognitive functioning required to fully engage in CBT-based programs. Second, many of the programs were not originally designed to target both anxiety and depression. Thus, the development and application of simpler transdiagnostic protocols that target common underlying symptoms of both disorders was warranted.

Accordingly, two novel prevention programs were developed: an emotion regulation-based (ER) program and a behavioural activation-based (BA) program. Both programs aimed to build resilience to manage worry, a symptom of both anxiety and depression. In so doing, both disorders could be targeted and prevented simultaneously. The first experimental study was a randomised controlled pilot study designed to assess the efficacy of the ER and BA programs against a control condition. There was a significantly greater increase in resilience for children who completed the BA program compared to the control condition. Additionally, expressive suppression (a maladaptive emotion regulation strategy) mediated the relationship between condition and worry for both programs. It was suggested that the relatively short follow-up period and the overly theoretical nature of the programs may have contributed to the lack of significant reductions in worry, anxiety and depression.

Both programs were revised based on the recommendations from the pilot study, and a second randomised controlled trial was conducted. This included a 12-month follow-up an assessment of the change in the percentage of participants who met the clinical cut-off scores for anxiety and depressive disorders over time, and a measure of working memory. Although there were no statistically significant changes in outcome variables, level of emotion regulation was found to mediate the relationship between condition and worry at post-program. Moreover, results showed that the percentage of children in the BA program who met the clinical cut-off scores for generalised anxiety disorder and major depressive disorder significantly reduced from baseline to 12-month follow-up. For those in the ER program, the percentage of participants who met the clinical cut-off score for obsessive compulsive disorder also significantly reduced at 12-month follow-up, indicating the clinical significance of the programs.

Collectively, the two studies show some promising results for the use of ER and BA as universal prevention programs. Suggestions for future research are proposed, such as investigating the effectiveness of the programs when delivered to a larger sample by school personnel, which may serve to provide benefits to a greater number of students at little cost to the schools involved.

Keywords: prevention, children, transdiagnostic, anxiety, depression, worry, resilience

Subject: Psychology thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Education, Psychology and Social Work
Supervisor: Professor Eva Kemps