their exposure to traumatic events. Further evaluative research regarding their utility for such purposes is needed, however. In addition, because many adolescent-onset problems such as cigarette smoking frequently co-occur with anxiety and its disorders, as noted earlier in this section, screening for anxiety with one of the anxiety symptoms scales (e.g., RCMAS, MASC) may be worthwhile to include, whenever beginning work with adolescents for any such problems.

Finally, Beidel and colleagues (Beidel & Turner, 1988; Beidel, Turner, & Trager, 1994) conducted a series of studies showing that the Test Anxiety Scale for Children (Saranson, Davidson, Lighthall, & Waite, 1958) could serve as a useful screen in identifying children who may show detectable symptoms of anxiety disorders, including social anxiety disorder, specific phobia, and generalized anxiety disorder. Clearly, as “high-stakes” testing (e.g., SATs, ACTs) becomes more of a stressor with adolescence, the potential utility of test anxiety as a marker, and the Test Anxiety Scale as a screen among adolescent samples, deserves scrutiny.

There are multiple access points for early detection and screening in healthcare settings, particularly in pediatrics, obstetrics-gynecology (ob-gyn), and psychiatry. The pediatric setting, for example, is the natural site for early detection and screening of young children with pediatric onset of either obsessive-compulsive disorder (OCD) or a tic disorder following an abrupt onset of symptoms after a group A β-hemolytic streptococcal infection, which is referred to as PANDAS (see Chapter 10). The MASC Obsessive-Compulsive Screener (March, Parker, et al., 1997), together with the Conners-March Developmental Questionnaire, may identify such cases; the former could be used to identify OCD symptoms in both pediatricians' and dermatologists' offices. Indeed, for a large proportion of families, the pediatrician office is the “first gate” they enter when their child or adolescent begins to show disturbances associated with anxiety and its disorders, such as somatic complaints and panic attack symptoms. It would thus seem critical for primary care physicians to have understanding of and knowledge about anxiety disorders so that they could inquire about the presence or absence of key symp toms of the various disorders (described in Chapter 9), and refer, as necessary, to a mental health professional for further evaluation based on the results of these initial queries.

Given the preponderance of female cases of anxiety disorders relative to male cases particularly from adolescence and beyond, ob-gyn settings represent yet another potentially useful and critically important access point for early detection and screening. Studies have demonstrated that pubertal maturation in adolescent girls, particularly early onset, may constitute a risk factor for developing anxiety symptoms and disorders (e.g., Caspi & Moffit, 1991; Graber, Brooks-Gunn, Paikoff, & Warren, 1994), particularly panic attacks (Hayward, Killen, Kraemer, et al., 1997). Such findings suggest the potential utility of educating physicians in the ob-gyn area about the risks of anxiety problems in their young adolescent female patients. The manner in which such young patients may become overly sensitive to the physical changes that occur during the menstrual cycle (i.e., high anxiety sensitivity) might be carefully considered and even assessed using the CASI (Silverman et al., 1991). Relatedly, research findings, albeit sparse, suggest that hormonal fluctuations during the female reproductive cycle may serve to either exacerbate or reduce anxiety symptoms and disorders. For example, among some women, the postpartum period may be a risk for the onset and exacerbation of anxiety symptoms and disorders (March & Yonkers, 2001). Also among some women, pregnancy may be a period when past episodes of panic disorder improves (Shear & Oommen, 1995). In light of such findings, it seems critically important that ob-gyn physicians carefully consider their female patients' emotional states during regularly scheduled appointments. Adult anxiety rating scales, such as the Hamilton Scales, may be worth administering as a potential screen for the presence of anxiety symptoms in these patients.

Finally, psychiatry departments housed in medical settings, community mental health settings, or in private practice represent yet another important, though again, largely untapped access point by which to conduct early detection and screening. In light of the strong evidence for familial transmission of anxiety disorders, adult

patients who present with anxiety disorders, depressive disorders, or both (Weissman, 1988) should be carefully queried about the functioning of their children and adolescents. For such purposes, parent rating scales such as the Child Behavior Checklist (CBCL; Achenbach, 1991) and the Connors Rating Scales (Conners, 1997) could be administered. Although parents with anxiety problems are likely to endorse high levels of internalizing problems in their offspring with the CBCL (e.g., Silverman, Cerny, Nelles, & Burke, 1988), some of which might be due to the parent's own pathology, as noted earlier, this initial step is a screen. Further follow-up would then be conducted with the children themselves by means of structured interview schedules, such as the Anxiety Disorders Interview Schedule for Children (ADIS-C): DSM-IV (Silverman & Albano, 1996). This interview schedule is the one most widely used in child and adolescent anxiety disorders and includes a child and a parent version. Previous research demonstrates good to excellent test-retest reliability for the diagnosis of anxiety disorders (e.g., κ = .63 to .83 for the ADIS-C child version, κ = .65 to .88 for the ADIS-C parent version, and κ = .80 to .92 for the composite diagnosis; Silverman, Saavedra, & Pina, 2001).

Finally, recent survey studies involving adults' reactions to the terrorist attacks of September 11, 2001 employed Web-based measures (e.g., Schuster et al., 2001), which allowed for efficient data collection from large numbers of subjects. The method is not without its shortcomings, however, the most prominent of which is the possibility of sampling bias: (1) those most interested in the topic and affected by the events might be most likely to participate, which will perhaps overestimate effects; and (2) despite the appearance of ubiquity in our culture, it is estimated that fewer than 50% of urban homes have personal computers, and thus Web-based surveys are likely to exclude large numbers of participants. It may be that use of Web-based surveys in the school context may be a useful way to proceed, however: it would avert a problem of having little unscheduled time during the school day to conduct research studies, and may improve participation among adolescents, who are increasingly computer- savvy. The problem of excluding youngsters who do not have a computer in their home could be addressed by allowing the use of school and/or researcher-provided laptops for this purpose.

These programs are most similar to the treatments for fully syndromal individuals with which the field is most familiar, in that patients are already experiencing symptoms of a disorder and are at high risk for the development of the full-blown syndrome. Harvey and Bryant (1998) reported that 78% of adult motor vehicle accident survivors who met criteria for acute stress disorder (ASD) suffered from PTSD 6 months after the trauma, compared to only 4% of survivors who did not meet criteria for ASD. Thus, ASD is considered a major risk factor for PTSD. It is important to note, however, that there are many shared features between the two disorders and this overlap may be the main contributor to the predictive relationship between ASD and PTSD. Indeed, severity of PTSD symptoms shortly after the traumatic event is a very strong predictor of PTSD severity later on. Foa, Hearst-Ikeda, and Perry (1995) conducted the first PTSD prevention study. Women who were recent victims of sexual and nonsexual assault and who met symptom criteria for PTSD received either a brief cognitive-behavioral therapy (CBT) program consisting of four weekly 1.5-hr sessions or four weekly assessments of their PTSD related symptoms. At 2 months postintervention assessment, the CBT group had a recovery rate of 10% for PTSD vs. 70% in the assessment control group. Using five sessions of Foa et al.'s prevention program (adding one additional session), Bryant, Harvey, Sackville, Dang, and Basten (1998) compared it to supportive counseling (SC) for male and female survivors of motor vehicle and industrial accidents who met diagnostic criteria for ASD. At posttreatment, only 8% of CBT participants met criteria for PTSD, compared to 83% of the SC patients. Although rates of PTSD increased over the course of a 6-month follow-up, CBT remained superior (17% PTSD incidence) to SC (67% PTSD incidence). In a subsequent study, Bryant, Sackville, Dangh, Moulds, and Guthrie (1999) modified the brief CBT by limiting it to psychoeducation and exposure, eliminating anxiety management (e.g., relaxation training) and cognitive restructuring, and compared this modified protocol to the full protocol and to SC. At posttreatment, 20% of participants in the full treatment program and 14% of participants in the brief CBT met criteria for PTSD, in comparison to 56% of participants in the SC condition. At 6 months, incidence of PTSD was 23%, 15%, and 67% for the full treatment program, exposure, and SC, respectively. In a more recent study, Foa, Zoellner, and Feeny (2004) again found that CBT accelerates recovery after sexual assault, compared to SC.

Another group presumably at risk for the development of an anxiety disorder is adults who present to emergency rooms with panic attack symptoms. Swinson, Soulios, Cox, and Kuch (1992) conducted an intervention study with such individuals, 40% of whom met full symptom criteria for panic disorder, thus rendering this study an indicated prevention/treatment hybrid. Nevertheless, at 6 months follow-up, participants randomized to a 1-hr exposure-based condition were improved on panic and anxiety measures, whereas those assigned to a 1-hr reassurance control intervention were no better. Subgroup analyses examining outcome for those with full syndromal panic disorder and those who were subthreshold were not reported, however. Gardenschwartz and Craske (2001) also targeted the prevention of panic disorder, but recruited college students who had experienced a panic attack within the last year, evidenced elevated anxiety sensitivity, and did not meet DSM criteria for panic disorder. Participants were randomly assigned to either a wait list or a day-long CBT workshop that included

psychoeducation about agoraphobia and panic, behavioral and cognitive strategies, and interoceptive exposure. At 6 months follow-up, 14% of the wait-list group had gone on to develop fully syndromal panic disorder, compared with only 2% of the workshop participants; significant effects were also seen on other relevant indices (e.g., panic attack frequency × intensity index). As the authors note, a longer follow-up period may not have yielded similar outcome, as the workshop's effects may have been transient.

Only two randomized control trials (RCTs) involving indicated prevention programs have been conducted using pediatric samples. LaFreniere and Capuano (1997) examined the effects of a program directed at mothers of preschool children (N = 43) exhibiting anxious or withdrawn behavior, comparing it to no treatment. The intervention lasted for 6 months and consisted of four phases: (1) assessment; (2) education of the parents about their child's developmental needs; (3) determination of specific objectives for the family; and (4) implementation of the intervention during 11 home visits with child-directed interaction, modification of behavior problems, training in parenting skills, and enhancement of the effectiveness of social support systems. Given the age of the children, outcome variables included teacher ratings in social competence within the preschool setting and cooperation and enthusiasm during a problem-solving task rather than symptoms of a specific anxiety disorder. Results indicated that maternal stress was reduced and anxious–withdrawn behavior of the child was significantly lower at posttreatment in both conditions, although the social competence of children whose mothers received the intervention was greater prior to intervention than that of those whose mother received no treatment. The relatively brief follow-up period and the lack of information about anxiety disorder symptoms limit the utility of the findings. Nevertheless, the study offers preliminary and encouraging findings about the potential benefit of such programs for behaviorally inhibited young children.

The second pediatric study, known as the Queensland Early Intervention and Prevention of Anxiety Project, constitutes the most comprehensive effort made thus far in evaluating the efficacy of a prevention program for children and adolescents (Dadds et al., 1997, 1999). As in the Swinson et al. (1992) adult panic disorder prevention study described above, Dadds et al.'s study can be better characterized as a hybrid-indicated prevention and early-intervention study because 55% of the selected children met diagnostic criteria for at least one anxiety disorder. A total of 1,786 children (ages 7 to 14 years) were screened for anxiety problems by use of teacher nominations and children's self-ratings. After initial diagnostic interviews, 128 children were selected and randomly assigned to either a 10-week school-based psychosocial intervention based on Kendall's Coping Cat protocol (2000a), or to a monitoring group. The intervention was conducted over 10 weekly, 1-to 2-hr sessions at each intervention school. Group sizes ranged from 5 to 12 children. Parental sessions were conducted at the intervention schools in weeks 3, 6, and 9. Anxiety disorder diagnostic status was assessed at posttreatment and at 6-month, 12-month, and 24-month follow-up and yielded interesting results: the CBT and control groups differed significantly with respect to anxiety disorder diagnostic status at 6 months (27% vs. 57%) and at 24 months (20% vs. 39%), but did not differ at 12-month follow-up (37% vs. 42%). Notably, treatment benefits were most evident for those children who initially had moderate to severe clinician ratings of severity, with approximately 50% of these children retaining a clinical diagnosis at the 2-year follow-up, if they did not receive the intervention. For those children who initially showed symptoms of anxiety but who did not have a clinically significant anxiety disorder, there was minimal difference between the preventive intervention and the monitoring-only condition at 24 months follow-up, with 11% showing an anxiety disorder in the intervention group and 16% in the monitoring condition. In other words, children with subclinical anxiety problems did not appear to be at high risk of developing a more severe anxiety disorder if left untreated and benefited only minimally from the intervention.

Selective prevention intervention programs are delivered to individuals or groups considered to be at high risk for anxiety disorders yet are not evidencing

anxiety disorder symptoms. There is a paucity of studies on these programs. To date, most selective prevention intervention programs have targeted individuals or groups exposed to stressful life events such as parental divorce (e.g., Alpert-Gillis, Pedro-Carroll, & Cowen, 1989; Hightower & Braden, 1991; Hodges, 1991; Short, 1998; Zubernis, Cassidy, Gillham, Reivich, & Jaycox, 1999); transition between primary and secondary school, which can be associated with a number of psychological difficulties (e.g., peer relationships, school refusal behavior, substance use; Felner & Adan, 1988); medical and dental procedures (Peterson & Shigetomi, 1981); and having a chronically ill sibling (e.g., Bendor, 1990). Although the findings from these studies generally yield positive effects, their direct relevance to preventing anxiety disorders in adolescents is unclear.

The only selective prevention intervention program designed specifically for anxiety disorders is the Macquarie University Preschool Intervention Program (Rapee, 2002). Children (ages 3.5 to 4.5 years) were recruited mainly via questionnaires distributed to preschools. Inclusion in the study was based on mother-completed ratings on the Australian version of the Childhood Temperament Scale (Sansan, Pedlow, Cann, Prior, & Oberklaid, 1996), followed up by laboratory observation of behavioral inhibition. Behaviorally inhibited children were randomly assigned to either an intervention condition or a monitoring condition. The intervention was conducted with parents only and focused on education about the nature of withdrawal and anxiety, parental anxiety management strategies, information about the importance of modeling competence and promoting independence, development of exposure hierarchies for the children and practice of graded exposure, and discussion of future development. The intervention was conducted in groups of six families and lasted for six sessions. Results at 12 months revealed that mothers in the intervention condition had self-ratings that indicated significantly greater decreases in their child's inhibited temperament as well as in the number of child anxiety diagnoses compared to mothers in the control condition. However, laboratory observations indicated that children in both groups had reduced behavioral inhibition with no significant differences between the two groups.

As an extension of the indicated prevention work conducted in Australia and reviewed above, encouraging preliminary data have emerged from a school-based FRIENDS program for children ages 10–12 years (Barrett & Turner, 2001) and a second sample of children ages 10–13 years (Lowry-Webster, Barrett, & Dadds, 2001). The FRIENDS acronym stands for Feeling worried; Relax and feel good; Inner thoughts; Explore plans of action; Nice work, reward yourself; Don't forget to practice; and Stay cool. The program is cognitive-behavioral in orientation, can be delivered by teachers or psychologists, is conducted weekly for 10 weeks and followed by booster sessions, and has been compared to an untreated control group. Children who received the intervention had lower self-rated anxiety levels than those of controls at posttreatment; moreover, no statistical differences were found in outcome when FRIENDS was delivered by either teachers or psychologists (Barrett & Turner, 2001). These preliminary reports are encouraging, although the full sample has yet to be accrued, and the follow-up period (6 months) is insufficient to determine whether participation in the program affects anxiety symptoms and the development of anxiety disorders in the long run, especially for those anxiety disorders (e.g., panic disorder) that are more likely to develop in adolescence than in childhood.

Lowry-Webster et al. (2001) randomly assigned 594 children (10 to 13 years) within different schools to receive either the FRIENDS program or assessment only. The intervention was implemented by trained classroom teachers and three separate sessions for parents were also conducted. Pre-to postintervention changes were examined universally and for children who scored above the clinical cutoff for anxiety at pretest. Results revealed that children in the FRIENDS intervention condition reported less anxiety symptoms, regardless of their risk status, relative to the comparison condition. Notably, those who were already in the clinically anxious range on the Spence Children's Anxiety Scale fared better in the FRIENDS program than in the