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This NIHR funded trial of an anxiety prevention programme in UK primary schools found it was effective after one year if led by health practitioners, but not after two years. The programme was not effective at all if led by a teacher. After two years, anxiety had reduced a similar amount for both the intervention group and controls, who received the usual curriculum, including personal, social and health education (PSHE) lessons. The nine-week programme, delivered in the classroom, is based on cognitive behavioural therapy (CBT) and leads nine- and ten-year-olds through activities and tasks that, through changing the way they think, help them to counter their anxieties. The cost of the FRIENDS programme was estimated to be from £52 to £56 per child and was unlikely to be cost-effective in UK primary schools in its current form. The findings suggest there is limited evidence to support implementation of the FRIENDS anxiety prevention programme in UK primary schools.

Why was this study needed?

Anxiety disorders affect around 10% of children by the age of 16 years. They significantly impair everyday life, often persist into adulthood and increase the risk of other psychiatric disorders. The economic and societal costs are considerable and rising. NHS service costs for anxiety disorders are projected to be £2 billion by 2026. Effective psychological interventions like CBT are available for children with anxiety disorders but surveys show only around one-third of children had sought or received specialist help.

The World Health Organization regards the FRIENDS programme as having strong evidence of effectiveness. The aim of this NIHR-funded trial was to investigate the clinical and cost-effectiveness of the FRIENDS programme, as delivered under everyday conditions by health and school professionals in UK primary schools. This is the first randomised trial of the FRIENDS programme or any similar preventative anxiety programme in UK schools.

What did this study do?

This was a cluster randomised controlled trial of 41 primary schools in the south-west of England. Schools were randomly assigned to one of three groups: school-led FRIENDS, health-led FRIENDS or the usual PSHE school curriculum. In total, the trial included 1,362 children aged 9 to 10 years.

The FRIENDS programme is a nine week, manual-based CBT intervention that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety (see Definitions tab for more details). School-led sessions were led by a teacher supported by two health facilitators, while the health-led sessions were led by two health facilitators supported by the teacher. The health facilitators were external to the school and were not mental health specialists but health professionals with a lower level of training or expertise, such as school nurses or psychology assistants. The leaders from both the health and school-led arms attended a two day training event to familiarise them with the programme.

The comparison group received usual school PSHE lessons, delivered by a single teacher.

What did it find?

  • After one year, children in the health-led FRIENDS group had a clinically significant reduction in anxiety symptoms compared to those in the school-led FRIENDS group (Revised Child Anxiety and Depression Scale score –3.91, 95% confidence interval (CI) –6.48 to –1.35). The health-led group also saw a reduction in anxiety compared to the usual school provision group (–2.66, 95% CI –5.22 to –0.09). The researchers had pre-defined a reduction of 3.6 points or more as clinically important. School-led FRIENDS groups were not found to be effective when compared to the usual school provision group.
  • After two years, anxiety had reduced across the board and there was no difference between the three groups. Less than half (43.6%) of the starting number of children were tested after two years, although baseline differences between completers and non-completers were minimal.
  • The FRIENDS programme was more faithfully implemented when health rather than school-led – not all of the core tasks and activities were delivered in the school led programmes.
  • The cost of the FRIENDS programme was estimated to be £52 to £56 per child for both health-led and school-led groups, respectively. Determining cost effectiveness in the study was difficult as the subgroup of children in whom service usage data were collected had different outcomes from those in the main trial. The team cautiously concluded there was no evidence that the FRIENDS programme was cost-effective.
  • Children enjoyed the programme and teachers felt that it provided the children with useful skills. Children and teachers liked the practical activities and group work, such as role play, scenarios and games, but felt that there was also too much passive learning, such as reading, writing and listening.

What does current guidance say on this issue?

NICE guidance from 2008 states that schools should have a comprehensive programme to help develop children's social and emotional skills and wellbeing. This should include a curriculum that integrates the development of social and emotional skills within all subject areas. These skills include problem-solving, coping, conflict management/resolution and understanding and managing feelings. This should be provided throughout primary education by appropriately trained teachers and practitioners. There is nothing in the current 2008 guidance advocating a specific programme to reduce anxiety and low mood such as the FRIENDS programme.

What are the implications?

The trial gives limited evidence to support the provision of FRIENDS - a specific anxiety prevention programme - in UK primary schools.  Health-led FRIENDS had clinically relevant benefits superior to the regular curriculum after a year, but these were not maintained after two years.

Overall, the current programme looked unlikely to be cost effective. Costing £52 to £56 per child, the FRIENDS programme may be beyond the finances available to most schools, if they were to pay for it themselves. Future work could identify whether the nine-week programme could be shortened to reduce the cost.

The manual-led programme resulted in different outcomes depending on who delivered it, suggesting this may have been an important success factor, at least in the first year. Identifying other reasons for success and failure would be valuable to the formation and or modification of future programmes.

The NIHR is funding studies that are evaluating three interventions designed to improve the wellbeing of school children. The interventions being evaluated are: “Promoting Alternative Thinking Strategies” (PATHS) to promote social and mental wellbeing among primary school children; the “Roots of Empathy” programme for improving social and emotional wellbeing; and “SHAHRP” – a school based alcohol harm reduction programme.


Stallard P, Skryabina E, Taylor G, et al. A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years. Southampton (UK): NIHR Journals Library; 2015 Nov.

This project was funded by the National Institute for Health Research Public Health Research programme (project number 09/3000/03)


Ford T, Goodman R, Meltzer M. Service use over 18 months among a nationally representative sample of British children with psychiatric disorder. Clin Child Psychol Psychiatry. 2003;8:37–51.

McCrone P, Dhanasiri S, Patel A, et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund; 2008.

NICE. Social and emotional wellbeing in primary education. PH12. London: National Institute for Health and Care Excellence; 2008.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

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The FRIENDS programme develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. Children develop emotional awareness and regulation skills to enable them to identify and replace anxiety-increasing thoughts with more balanced and functional ways of thinking, and to develop problem-solving skills to confront and cope with anxiety-provoking situations and events. The programme therefore teaches children skills to identify and manage their anxious feelings, develop more helpful (anxiety-reducing) ways of thinking and face and overcome fears and challenges rather than avoid them.


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